Lesson 5: Basic Care and Comfort
Questions are numbered by the order in which they
appeared in the test.* Represents the correct answer.
The nurse is planning care for a client with acerebral vascular accident (CVA). Which of thefollowing measures planned by the nurse would be
effective in preventing skin breakdown?A)Place client in the wheelchair for four hours each dayB) Pad the bony prominenceC) Reposition every two hoursD)
Massage reddened bony prominence
: The correct answer is C:Reposition every two hoursClients who are at risk for skin breakdowndevelop fewer pressure ulcers when turned everytwo hours. By relieving the pressure over bony prominences at frequent scheduled intervals, blood flow to areas of potential injury ismaintained.
After a client has an enteral feeding tubeinserted, the
accurate method for verification of placement isA) abdominal x-rayB) auscultationC) flushing tube with salineD)
aspiration for gastric contents
: The correct answer is A:abdominal x-rayPlacement should be verified by radiograph todetermine that the tube is in the stomach or intestine rather than in the airways.
The nurse has been teaching a client withcongestive heart failure about proper nutrition.Which of these lunch selections indicates theclient has learned about sodium restriction?A) Cheese sandwich with a glass of 2% milk B)Sliced turkey sandwich and canned pineappleC) Cheeseburger and baked potatoD)
Mushroom pizza and ice cream
: The correct answer is B:Sliced turkey sandwich and canned pineappleSliced turkey sandwich is appropriate since it isnot a highly processed food and canned fruits arelow in sodium. All of the other choices containone or more high-sodium foods.
The nurse is caring for a 7 year-old with acuteglomerulonephritis (AGN). Findings includemoderate edema and oliguria. Serum blood ureanitrogen and creatinine are elevated. Whatdietary modifications are
appropriate?A) Decreased carbohydrates and fatB) Decreased sodium and potassiumC) Increased potassium and proteinD)
Increased sodium and fluids
: The correct answer is B:Decreased sodium and potassiumChildren with AGN who have edema,hypertension oliguria, and azotemia have dietaryrestrictions limiting sodium, potassium, fluids,and protein.
After a myocardial infarction, a client is placedon a sodium restricted diet. When the nurse isteaching the client about the diet, which meal plan would be the
appropriate to suggest?A)3 oz. broiled fish, 1 baked potato, ½ cupcanned beets, 1 orange, and milk B)3 oz. canned salmon, fresh broccoli, 1 biscuit, tea, and 1 appleC)A bologna sandwich, fresh eggplant, 2 ozfresh fruit, tea, and apple juiceD)
3 oz. turkey, 1 fresh sweet potato,1/2 cup fresh green beans, milk,and 1 orange
: The correct answer is D: 3oz. turkey, 1 fresh sweet potato, 1/2 cup freshgreen beans, milk, and 1 orangeCanned fish and vegetables and cured meats arehigh in sodium. This meal does not contain anycanned fish and/or vegetables or cured meats.
What finding of the nursing assessment of a paralyzed client would indicate the probable presence of a fecal impaction?A) Presence of blood in stoolsB) Oozing liquid stool