HURST REVIEW Qbank/Customize Quiz - Basic Care and Comfort 2022

The nurse is teaching a client about the use of a cane. Which is the correct cane technique? 1. Place the cane on weaker side of the body to support the weaker leg. Using the cane for support, the client should step forward with strong leg, and then move the weaker leg and cane forward to the strong leg. 2. Place the cane on the stronger side of the body. The cane is placed forward 6 to 10 inches while the client advances the weak leg at the same time. 3. Place cane on weaker side of body. The cane is placed forward 6 to 10 inches while the client advances weaker leg to the cane. 4. Place cane on stronger side of body to help support weaker leg. Using cane for support, step forward with the strong leg and then move the weaker leg and the cane forward to the strong leg. 2. Correct: Place the cane on the stronger side of the body. The cane is placed forward 6 to 10 inches while the client advances the weak leg at the same time. The body weight is divided between the strong leg and the cane. 1. Incorrect: The cane should be on the stronger side of the body to create a wider base for balance as the client advances the strong leg and must use the weaker leg for support with the cane. If the cane is placed on the weaker side of the body, this would create a narrower base for support and balance and increase the risk of falling. 3. Incorrect: The cane should be on the stronger side of the body to create a wider base for balance as the client advances the strong leg and must use the weaker leg for support with the cane. If the cane is placed on the weaker side of the body, this would create a narrower base for support and balance and increase the risk of falling. 4. Incorrect: The cane should be on the stronger side of the body to create a wider base for balance as the client advances the strong leg and must use the weaker leg for support with the cane. If the cane is placed on the weaker side of the body, this would create a narrower base for support and balance and increase the risk of falling. Which action by two unlicensed nursing personnel (UAPs), while moving the client back up in bed, would require intervention by the nurse? 1. Lowers the side rails closest to them. 2. Places hands under client's axilla. 3. Lowers the head of bed. 4. Raises the height of the bed. 2. Correct: This action is not appropriate and requires intervention by the nurse. This could damage the brachial plexus nerves under the axilla. Use a draw sheet to prevent this from occurring. 1. Incorrect: This is a correct action. The UAPs will need to lower the side rails closest to them to safely move the client up in bed. Not lowering the rails could injury the UAPs back. 3. Incorrect: This action is correct. Moving the client upward with the head of the bed raised works against gravity, requires more force and can cause back strain. 4. Incorrect: This action is appropriate and would not require intervention by the nurse. Raising the height of the bed brings the client close to the UAPs center of gravity and decreases the chance of back injury. Which action would the nurse need to perform to increase stability while initiating a client transfer? 1. Lift with the back. 2. Put on a back belt. 3. Spread feet to width of the shoulders. 4. Lean forward slightly. 3. Correct: In order to increase stability, the nurse will need to increase the base of support. This can be done by spreading the legs to the width of the shoulders. 1. Incorrect: Do not use your back to do heavy lifting. They are not your strongest muscles. Use your legs. 2. Incorrect: A back belt will not increase the base of support. 4. Incorrect: The nurse should not lean forward or backward. The ears, shoulders, hips and feet should be aligned. A nurse is monitoring a newly hired unlicensed assistive personnel (UAP) perform a bed bath on a client needing total care. Which action by the UAP would require further teaching? Select all that apply 1. Lowers side rails on both sides of bed. 2. Washes eyes with mild soap and water from the inner to outer canthus. 3. Makes certain bath water temperature is between 110-115°F (43-46°C). 4. Uses long, firm strokes to wash from wrist to shoulder of each arm. 5. Performs a back massage after completing the bath. 1., & 2. Correct: The nurse needs to intervene in these situations. Both side rails should not be lowered because the client could fall out of the bed. The UAP should lower the side rail closest to themselves and keep the opposite rail up. Wash eyes with water only since soap is very irritating to the eyes. 3. Incorrect: This would be a correct action by the UAP. The nurse does not need to intervene. Temperatures less than 110°F (43°C) can chill the client, and a temperature greater than 115°F (46°C) may be too hot and burn the client. 4. Incorrect: This is a correct action and does not require intervention by the nurse. Firm strokes from distal to proximal areas promote circulation by increasing venous blood return. 5. Incorrect: A back massage is appropriate after a bath and does not require nursing intervention. A back massage is a way of providing relaxation for the client. The nurse is repositioning a client who is in the supine position to the right lateral position. Which nursing intervention would be implemented to position the client in the right lateral position? 1. The right leg is positioned on a pillow in front of the left leg. 2. Both knees are kept in the extension position. 3. Both feet are placed in the inversion position. 4. The left shoulder should be positioned forward. 4. Correct: The left shoulder should be adducted. The position of adducting the shoulder forward promotes improved chest expansion and decreases strain on the shoulder. 1. Incorrect: The right leg is positioned forward in the left lateral position. For the right lateral position, the left leg is positioned on a pillow in front of the right leg. 2. Incorrect: Both legs should not be extended for the right lateral position. The left leg should be positioned forward with the knee flexed to decrease the internal rotation of the femur. 3. Incorrect: Inversion of the feet is described as positioning the ankles toward the midline of the body. The feet should be positioned in the neutral position to maintain proper ankle alignment. A nurse is performing eye care for an unconscious client. Which interventions should the nurse include? Select all that apply 1. Administer moist compresses to cover eyes every 2 hours. 2. Clean eyes with saline and cotton balls, wiping from outer to inner canthus. 3. Use a new cotton ball for each cleansing wipe. 4. Instill artificial tears into the lower eyelids as prescribed. 5. Protect the eyes with a protective shield. 6. Monitor eyes for redness and exudate. 1., 3., 4., 5., & 6. Correct: All of these interventions are appropriate for eye care of the comatose client. These actions prevent infection, keep eyes moist, and protect the eye from injury. 2. Incorrect: Clean the eyes with saline solution and cotton balls. Wipe from the inner to outer canthus. This prevents debris from being washed into the nasolacrimal duct. A nurse is planning a teaching session for a group of clients diagnosed with irritable bowel syndrome. What points should the nurse include to help the clients control symptom flare-ups? Select all that apply 1. If you are constipated, try to make sure you have breakfast. 2. Avoid low fat foods. 3. If you think a certain food is a problem, try cutting it out of your diet for about 12 weeks. 4. Drinks containing caffeine are likely to contribute to symptoms. 5. Foods such as broccoli and cabbage are good sources of fiber. 1., 3. & 4. Correct: If you are constipated, try to make sure you eat breakfast, as this is the meal that is most likely to stimulate the colon and give you a bowel movement. If you think a certain food is a problem, try cutting it out of your diet for about 12 weeks. (If you suspect more than one, cut out one at a time so you know which one causes you problems.) If there's no change, go back to eating it. The foods most likely to cause problems are: Insoluble (cereal) fiber; Coffee/caffeine; Chocolate; Nuts. 2. Incorrect: Avoid meals that over-stimulate the gut, like large meals or high fat foods. 5. Incorrect: Broccoli and cabbage are common gas-producing foods that can cause abdominal distention and flatulence. A client being discharged home following hip surgery is prescribed to use a walker. While observing the client walk across the room, the nurse is most concerned when the client does what? 1. Applies shoes securely before ambulating with walker. 2. Checks walker to be certain the legs are securely locked. 3. Slides walker slowly forward when walking across the room. 4. Places walker to right of the chair after sitting down in chair. 3. CORRECT: The nurse is observing the client ambulate with a walker prior to discharge, to determine whether the client is using the assistive device safely. The nurse becomes concerned upon noting the client sliding the walker during ambulating. The correct use of a walker involves the client lifting and placing the walker approximately one-foot length ahead, then stepping into the non-moving walker. It is important for the walker to remain stationary when the client takes a step forward. 1. INCORRECT: This action by the client is appropriate. Proper, gripping footwear should be worn by the client at all times when ambulating. This prevents the possibility of slipping and falling. There is no cause for concern with this action. 2. INCORRECT: Another smart move is to verify the cross bars are securely locked before ambulating. When a walker is folded for storage, the locks are unlatched. When the walker is open, the locks must click into place to verify the device is safe for ambulating. No concerns here. 4. INCORRECT: When a client sits down, the walker can be placed to either side of the chair. The most important factor is for the client to use the walker to safely maneuver into the chair rather than placing the walker aside before sitting down. Placing the walker next to the chair after being seated is appropriate. The nurse is caring for a client immediately following a bilateral salpingo-oophorectomy. Which position would be best for this client? 1. Fowler's 2. Modified Sims 3. Side-lying 4. Supine 3. Correct: We want to position for comfort with the knees flexed and on the side for airway. 1. Incorrect: Avoided to prevent pooling and edema in pelvis. 2. Incorrect: Partial lying on stomach is going to be painful. 4. Incorrect: Stretching out straight puts pressure on the abdomen and should be avoided. The primary healthcare provider has prescribed ear irrigation for a client with earwax accumulation. In what order would the nurse perform the procedure? Remove any debris in the outer canal. Squeeze syringe with moderate force. Aim syringe at back side of ear canal. Tilt client's head to the opposite side. Fill bulb syringe with lukewarm water. Pull ear pinna upward and backward. Drag and Drop the items from one box to the other Ear wax is a substance produced by the body to clean and protect the ear canal. Usually, the ear is able to remove wax that has dried up and become useless. However, in certain circumstances, a nurse may receive a prescription to irrigate ears for clients when the wax has become impacted. After gathering the needed equipment and explaining the process to the client, the nurse should first fill the bulb syringe with warm water. Next, positioning the client is always the nurse's responsibility. For irrigating ears, the client's head should be tilted slightly toward to opposite side, so the affected ear is easily accessible. Third, using one hand, the nurse pulls the ear pinna gently upward and back to straighten the ear canal. Fourth, aim the bulb syringe toward the back and side of the ear canal. Next, the nurse squeezes the syringe with moderate force to flush out loose debris or dried wax. Sixth, any debris visible in the outer canal can be carefully removed with tweezers. The nurse enters a client's room to administer morning medications and notes that the client is praying aloud. What would be the nurse's best action? 1. Interrupt the client to administer the medications. 2. Wait quietly until the prayer is finished. 3. Join the client for the prayer. 4. Ask the client if you can provide a directed prayer. 2. Correct: This is the best action by the nurse as this is a private spiritual moment for the client. Prayer is a self-care strategy that provides comfort, increases hope, and promotes healing and psychological well-being. The nurse could either leave and return later or wait quietly for the client to finish. 1. Incorrect: Administering the medications can wait until the client finishes the prayer. 3. Incorrect: Do not assume that the client wants others to join in the prayer. This is a private moment for the client. 4. Incorrect: Do not assume that the client wants others to join in the prayer. Don't interrupt the client while praying. The nurse is caring for a Puerto Rican client. The client has several injuries from a car accident and is experiencing pain. Which behavior is likely to be noted? 1. Loud crying with pain. 2. Enduring the pain in order to bring honor. 3. Quiet and stoic responses to pain. 4. Refusing pain medication because it is God's will. 1. Correct: Puerto Rican clients tend to cope with pain by loud and outspoken reports of pain. This is consistent with Puerto Rican culture and their response to pain. 2. Incorrect: Quietly enduring pain is consistent with the Japanese culture. This is consistent with the Asian culture and brings honor. 3. Incorrect: Stoic responses are consistent with Asian culture. The client is likely to be quiet about the pain thinking that complaints of pain will bring dishonor to the family. 4. Incorrect: Filipino clients tend to view pain as God's will. They may refuse medication to relieve the pain. A client with a history of deep vein thrombosis (DVTs) is being instructed on how to apply compression stockings prior to discharge. What statement alerts the nurse the client may be noncompliant when at home? 1. "I will follow the special diet in order to lose weight." 2. "I should walk a little every few hours after sitting." 3. "My husband can help remind me not to cross my legs." 4. "The stockings are too difficult to put on every morning." 4. CORRECT: Compression stockings are used to prevent the formation of blood clots, reduce the diameter of distended veins and decrease stasis. Usually these stockings are ordered to be applied upon rising in the morning and removed at night, depending on the disease process. The client's comment suggests the difficulty of putting the hose on may lead to not wearing the stockings consistently. 1. INCORRECT: This statement by the client indicates a positive attitude about the need to lose weight and the intention of following the prescribed diet. Obesity is one of several main factors that can lead to the development of DVTs. 2. INCORRECT: Prolonged sitting, or even lying down, can increase the incidence of blood clots or DVTs. If the client does a lot of sitting during the day, it is advisable to walk around every few hours to reduce stasis. The client is acknowledging the need to increase mobility regularly, which is an indication of compliance. 3. INCORRECT: Placing pressure directly on vessels by crossing the legs compresses both veins and arteries, thus increasing the potential for blood clots or dislodging an unknown clot. The client has acknowledged the need to keep legs uncrossed and the benefit of having family provide reminders. Which food item would the nurse include when planning diet instructions to promote bone growth for a client with a broken tibia? 1. Lettuce 2. Apples 3. Yogurt 4. Green beans 3. Correct: The serving size of 150 g of yogurt has a calcium content of 240 mg. 1. Incorrect: The serving size 50 g of lettuce has a calcium content of 19 mg. 2. Incorrect: The serving size of 182 g of apple has a calcium content of 11 mg. 4 Incorrect: The serving size of 90 g cooked green beans has a calcium content 50 mg. The parents of a 4 year old child have recently had a new baby and the parents report that the 4 year old had been dry all night for 8 months and is now wetting the bed again. What should the nurse assess first? 1. Urinalysis 2. Normal urination habits. 3. Adjustment to the new baby. 4. Fluid intake after 6 pm. 1. Correct: Always assess the physiologic problem first to rule out a urinary tract infection (UTI). Once a physiologic cause is removed as the cause other assessment should be performed. If a UTI is present, treatment should start immediately. 2. Incorrect: Assessing the normal urination habits is not first. Assessing the urinalysis is priority. 3. Incorrect: Regression is the likely cause but the physiologic problems should be assessed first. 4. Incorrect: The child's fluid intake may be too high after 6 pm, but ruling out a urinary tract infection is the first assessment and requires immediate treatment if there is an infection. The nurse is making an initial home visit to a client newly diagnosed with diverticulitis. The client had been on a liquid diet but is now to begin solid foods appropriate for the disease process. The nurse knows dietary teaching has been successful when the client selects which meal? 1. Hamburger on sesame roll, macaroni and cheese, tossed salad 2. Lamb chop with brown rice, cooked broccoli, baked potato 3. Pork with sauerkraut, baked beans, and coconut cake 4. Spaghetti with meatballs, fruit cocktail, garlic bread 4. CORRECT. Diverticulitis is an inflammation within the small, outpouching which can develop in the colon. A low residue/low fiber diet limits the amount of food waste passing through the large intestine, allowing the intestinal tract to rest and heal. Cooked pasta, along with ground, well cooked meatballs, is tolerated well. Canned fruits like fruit cocktail are far better than fresh fruit to control diarrhea and cramping. Garlic bread is also acceptable. 1. INCORRECT. A hamburger is well ground, cooked meat, which is acceptable for this client, but not when served on the sesame roll. Seeds and nuts tend to lodge in the diverticula, leading to pain or infection. Macaroni and cheese is a great menu item for the client. However, fresh vegetables, though healthy, do not breakdown easily, resulting in large amounts of undigested material passing through, or getting stuck, in the large intestine. 2. INCORRECT. Lamb is an acceptable as part of a low residue diet, but clients are instructed to eat white rice rather than the whole grain brown rice. Vegetables which create gas even when cooked, such as broccoli, could lead to a serious exacerbation of diverticulitis. Well cooked potatoes are permitted, but not if prepared with the skin, such as the baked potato. 3. INCORRECT. Several parts of this menu selection present a major problem for the client; in fact, only the pork is acceptable. Sauerkraut is prepared cabbage, and even when cooked, causes digestive and gas issues. Baked beans should be avoided for the same digestive reasons, and coconut is in the category with nuts or seeds. A terminal client begins reminiscing about the past, expressing grief and regret over life choices. What response by the nurse would best help the client cope at this time? 1. "You can't change the past so try not to dwell on it." 2. "Would you like me to call a priest for you to talk with?" 3. "You still have time to make amends if you want." 4. "I can sit here with you while you continue to talk." 4. CORRECT: Anytime a client expresses the desire to talk, the nurse should respond with an open-ended response, encouraging the client to continue to verbalize in a non-judgmental environment. More importantly, the nurse should remain with the client, even if there is no talking, to provide visual comfort. 1. INCORRECT: This non-therapeutic response denies the client's right to review past events or express feelings, which is a normal reaction at end of life. The nurse's closed response does not provide the client with the opportunity to verbalize. 2. INCORRECT: The nurse is ignoring the client's need to talk and is transferring care away to another individual, even if that individual is a clergyman. This is an incorrect action. 3. INCORRECT: While the client may regret some life choices, there is no mention of the desire or need to correct the past. The nurse is making an assumption. The nurse is evaluating an elderly bedridden client for possible fecal impaction. What sign/symptom should the nurse report as most indicative for a fecal impaction? 1. Rigid, board-like abdomen 2. Absence of any bowel sounds 3. Diarrhea with severe cramping 4. Constipation with liquid seepage 4. CORRECT. A client may have several symptoms with a fecal impaction; however, the most classic symptom which the nurse should report is the presence of constipation in the presence of liquid fecal seepage from the rectum. The client may also report abdominal distention with a feeling of fullness, cramping or even painful defecation. 1. INCORRECT. Although the client may report abdominal pain, a rigid, board-like abdomen is indicative of peritoneal inflammation such as peritonitis. As pain increase, the abdominal muscles respond by becoming rigid, hence giving the board-like appearance. 2. INCORRECT. A complete absence of bowel sounds is indicative of other bowel issues, such as a paralytic ileus, which occurs when peristalsis has completely stopped. That is not the case with an impaction. 3. INCORRECT. Diarrhea, especially with cramping, may be attributed to a variety of illnesses, including gastroenteritis, Crohn's disease or even ulcerative colitis. Additionally, diarrhea is not the same as liquid seepage. A palliative care client is suffering from persistent diarrhea. What foods should the nurse suggest? Select all that apply 1. Applesauce 2. Rice 3. Bananas 4. Tea 5. Yogurt 1., 2., & 3. Correct: The BRAT diet is recommended for clients with persistent diarrhea. This diet consists of bananas, rice, applesauce, and toast. Rice and potatoes help to reduce diarrhea. Bananas will help replace potassium. Once the diarrhea subsides, the client can add easily digestible foods like eggs. 4. Incorrect: Avoid coffee and tea because caffeine containing beverages may have a laxative effect. Caffeine is a stimulant and will increase the peristalsis even more. 5. Incorrect: Dairy products may make the diarrhea worse. Avoid these until the diarrhea subsides. What should the nurse check when assessing a client's balance? Select all that apply 1. Walking on tiptoes 2. Babinski reflex 3. Romberg test 4. Muscle strength of legs 5. Dorsalis pedis pulses 1., 3., & 4. Correct: Asking the client to walk on the tips of the toes assesses foot strength and balance. Muscle strength is needed to maintain balance and a Romberg's test asks the client to stand erect with arms at their side and feet together. The nurse notes any sway or unsteadiness. Then the client does the same thing with their eyes closed for 20 seconds again noting imbalance and sway. A positive Romberg is seen with swaying and moving feet apart to prevent a fall. It indicates a problem with balance. 2. Incorrect: Babinski sign is an important neurologic examination based upon what the big toe does when the sole of the foot is stimulated. If the big toe goes up, that may mean trouble with the central nervous system. This is not part of assessment for balance. 5. Incorrect: Assessing the dorsalis pedis pulse is done as part of a circulatory check not while assessing balance. An infant has been prescribed Bryant's traction for a diagnosis of developmental dislocated hips (DDH). At what degree of hip flexion should the nurse maintain the infant's hip for proper traction alignment? 1. 15 2. 30 3. 45 4. 90 4. Correct: Bryant's traction is used for DDH. The child's body and the weights are used as tension to keep the end of the femur in the hip socket. Traction helps position the top of the femur into the hip socket correctly. This is accomplished with 90 degrees of hip flexion. 1. Incorrect: Fifteen degrees of flexion is not adequate to keep the femur end in the hip socket. 2. Incorrect: Thirty degrees of flexion is not adequate to keep the femur end in the hip socket. 3. Incorrect: Forty-five degrees of flexion is not adequate to keep the femur end in the hip socket. Which food items, if chosen by a new unlicensed assistive personnel (UAP), would indicate to the nurse that the UAP understands a clear liquid diet? Select all that apply 1. White grape juice 2. Gelatin 3. Vanilla pudding 4. Lemon Popsicle 5. Fat free Broth 6. Tea with honey 1., 2., 4., 5., & 6. Correct: A clear liquid diet is made up of only clear fluids and foods that are clear fluids when they are at room temperature. These choices are considered to be clear liquids. 3. Incorrect. This is considered appropriate for a full liquid diet. The nurse is observing a new nurse inserting a nasogastric (NG) tube. Which action by the student nurse needs to be corrected by the nurse? Select all that apply 1. Measures from the tip of the nose to the xiphoid process of the client. 2. Lubricates the NG tube with petroleum gel. 3. Aspirates the NG tube to test gastric contents with a pH stip. 4. Marks the tubing at measurement mark with tape and secures to nose. 5. Places tube end into a glass of water to assess for bubbling. 1., 2., & 5. Correct: These actions by the new nurse are not done properly. The measurement for tube placement should be nose to ear and then xiphoid process. Lubricate the tube with a water solution, not a petroleum gel. Never place the tube in water because if the tube is in the trachea, the client can aspirate the water into the lungs. 3. Incorrect: This is the proper technique for checking placement of the NG tube. The pH should be less than 5 if in the stomach. 4. Incorrect: Yes, the tubing should be marked with a piece of tape and secured to the nose with tape or a commercial device if available. Which discharge instruction should the nurse implement for a client diagnosed with insomnia? Select all that apply 1. Eliminate chocolate in the evening. 2. Drink a glass of red wine 1 hour prior to bedtime. 3. Perform progressive relaxation techniques at bedtime. 4. Take acetaminophen/diphenhydramine 2 tablets at bedtime. 5. Leisurely walk 3 hours prior to bedtime. 6. Increase the airflow on the continuous positive airway pressure (CPAP) machine. 1., 3., & 5. Correct: Consuming chocolate in the evening may cause insomnia. Chocolate contains caffeine and xanthines which are stimulates. The chemicals will suppress melatonin and increase the time to fall asleep. Progressive relaxation techniques are recommended to reduce insomnia. This exercise is a systematic relaxation and tensing of the muscle groups of the body. Insomnia is reduced by increasing muscle relaxation and decreasing the stress level of the client. Non Strenuous exercises such as a leisure walk performed within 3 hours of bedtime promotes the reduction of the client's stress level. 2. Incorrect: Consuming alcohol prior to bedtime is not recommended. Alcohol consumption increases the start of sleep but reduces rapid eye movement (REM) sleep. The side effect of the alcohol may also cause the client to awaken during night and have difficulty returning to sleep. 4. Incorrect: Diphenhydramine is not recommended for insomnia. The action of the diphenhydramine may cause the client to feel drowsy but provides only temporary increase in quantity of sleep. The hypnotic effect of diphenhydramine will cause client to experience decrease energy levels the next morning. 6. Incorrect: A CPAP is prescribed for a client with obstructive sleep apnea not insomnia. The CPAP machine delivers a constant air pressure to the lungs. The constant air flow will keep the airway open during sleep. The nurse is planning care for four clients with different medical issues. With which diagnosis would a client benefit most from an integrative medicine healthcare strategy? 1. Chronic fatigue syndrome who has had no relief of fatigue. 2. Diabetes whose blood sugars are out of control and refuses to take the prescribed oral and injection medications. 3. Cholecystitis who wants surgery to treat the symptoms definitively. 4. Productive cough with green sputum, fever of 104.2 degrees Fahrenheit (40.1 degrees C), and chest pain. 1. Correct: Chronic fatigue syndrome is a chronic health problem that is difficult to treat using only traditional medicine and responds well to the use of an integrative medicine healthcare strategy by using a combination of traditional and holistic therapies. Integrative medicine is an approach to care that puts the patient at the center and addresses the full range of physical, emotional, mental, social, spiritual and environmental influences that affect a person's health. 2. Incorrect: Clients with acute illness symptoms are more appropriately treated with traditional medicine strategies. 3. Incorrect: Clients with acute illness symptoms are more appropriately treated with traditional medicine strategies. 4. Incorrect: Clients with acute illness symptoms are more appropriately treated with traditional medicine strategies. In what order will the nurse provide instructions to a client on using a cane? Advance weaker leg forward toward the cane. Move cane forward 6-10 inches (15 - 25 cm). With cane on stronger side of body, support body weight with both legs. Advance stronger leg forward toward cane. Drag and Drop the items from one box to the other First, with cane on stronger side of body, support body weight with both legs. This will support the even distribution of weight away from the weaker side to promote a normal gait. Second, move cane forward 6-10 inches (15-25 cm). Moving the cane the approximate distance of a normal gait helps with stability. Third, advance weaker leg forward toward the cane. This allows the weight to be supported by the cane and the stronger leg. Fourth, advance stronger leg forward toward the cane. This allows the weight to be supported by the can and weaker leg. The nurse is performing sterile wound care for partial thickness burns on a client's lower right leg. Prior to initiating this procedure, what action should the nurse complete first? 1. Position client upright with right leg elevated. 2. Obtain wound culture before cleaning wound. 3. Assess current pain level and medicate. 4. Encourage client to verbalize concerns. 3. Correct: Wound care on burns is a painful process, particularly with partial thickness burns (formerly referred to as second degree) because nerve endings are intact and exposed. Pre-medicating is a priority action, since pain medication can take up to 30 minutes to activate within the body. Clients are more cooperative and heal faster when pain is well controlled. 1. Incorrect: Proper visualization during wound care is vital, as is client comfort during the procedure. However, completion of this process does not require the client to be in an upright position. In fact, that may be counter productive at this time. Additionally, whether the right leg needs elevated depends on the size or location of the burn on the right leg, and that information has not been provided in the question. 2. Incorrect: While it is true that any wound culture must be obtained prior to cleaning the affected area, this action is not presently the nurse's first priority. Consider the nursing process and choose another option. 4. Incorrect: Therapeutic communication is an ongoing process during any client interaction, particularly when the nurse needs to explain an upcoming procedure. Allowing the client to express fears, verbalize concerns or ask questions enhances cooperation. Although this exchange of information is occurring throughout this period of time, the nurse has another priority action that should be completed first. Which meal option should the client diagnosed with gout select? 1. Tuna salad on bed of lettuce, apple slices, coffee 2. Vegetable soup, whole wheat toast, skim milk 3. Roast beef with gravy sandwich, baked chips, diet coke 4. Spinach salad with chickpeas and asparagus, apple, tea 2. Correct: Gout is pain and inflammation that occurs when too much uric acid crystallizes and deposits in the joints. This is a good choose as it is low in purine and fat. Purines are broken down into uric acid. A diet rich in purines can raise uric acid levels. Meat and seafood increase the risk of gout. Dairy products may lower risk for gout. 1. Incorrect: The client should not eat tuna, which is high in purine. 3. Incorrect: Gravy is a high purine food and should be avoided. Also avoid artificial sweeteners. 4. Incorrect: Although spinach, and asparagus can be consumed in moderation, they still contain purines, so it is not as good of a choice as the vegetable soup, toast and skim milk. An elderly client has been admitted to the hospital with a diagnosis of cerebral vascular accident (CVA) with right-sided paralysis. When the nurse instructs staff to reposition client every two hours, the family asks about the purpose of this action. What is the best explanation by the nurse? 1. Improves circulation to the affected side of the body. 2. Decreases potential skin breakdown from immobility. 3. Prevents blood stasis in the client's lower extremities. 4. Alleviates sensory deprivation by varying environment. 2. CORRECT. An immobile client is subjected to shearing forces and tissue breakdown because of prolonged contact between the skin and linens. Pressure sores can develop quickly when a client remains in one position over long periods of time, particularly on protruding areas of the body such as hips, elbows, sacrum or heels. Repositioning the client every two hours decreases the potential for skin breakdown and allows for inspection of all vulnerable body areas. 1. INCORRECT. While moving a paralyzed client might stimulate the overall circulation, and even allow for passive range of motion, repositioning a client does not specifically increase blood flow to one side of the body. 3. INCORRECT. Though moving a client can stimulate the circulation, repositioning every two hours is not sufficient to prevent blood stasis in lower extremities, particularly when this client cannot move the right side independently. 4. INCORRECT. Sensory deprivation is not a major concern for the client initially and repositioning is not meant to address sensory needs. The purpose of repositioning is prevention of skin breakdown. The community health nurse is planning to teach nutritional education to a group of adults attending a health fair. What tips about health eating should the nurse include? Select all that apply 1. Pay attention to fullness cues during meals. 2. Make one fourth of the plate fruits and vegetables. 3. Drink sweet tea rather than soft drinks with meals. 4. Eat foods low in dietary fiber. 5. Consume less than 30% of calories from saturated fatty acids. 6. Use a smaller plate for meals. 1., & 6. Correct: Pay attention to hunger and fullness cues before, during, and after meals. Use them to recognize when to eat and when you have had enough. Portion out foods before eating. A smaller plate will make the amount of food look larger. 2. Incorrect: Make half the plate fruits and vegetables. 3. Incorrect: Cut calories by drinking water or unsweetened beverages rather than drinks with sugar, such as soft drinks and sweet tea. 4. Incorrect: Diets should be high in fiber coming from fruits, vegetables, and whole grains. 5. Incorrect: Individuals should consume less than 10% of calories from saturated fatty acids (approximately 20 grams of saturated fat per day in a 2000 calorie diet).