Basic Care Flashcards

A nurse is applying elastic compression stockings to a client. Which assessment finding would require the nurse to withhold the stockings and notify the physician?

Answer: Cool, mottled skin on the lower extremities

Cool, mottled skin suggests compromised peripheral circulation, and applying compression stockings could further impair blood flow.

A nurse is preparing to apply a dry sterile dressing to a wound. After performing hand hygiene and opening the sterile field, the nurse accidentally touches the edge of the sterile drape. What should the nurse do?

Answer: Discard the entire sterile field and start over

A contaminated sterile field cannot be made sterile again; the nurse must discard all supplies and establish a new sterile field.

A client who is immobile is at risk for contractures. Which nursing intervention is most effective for preventing this complication?

Answer: Performing passive range-of-motion exercises at least twice daily

Passive range-of-motion exercises maintain joint flexibility and muscle length, directly preventing the development of contractures.

A nurse is preparing to transfer a client from the bed to a wheelchair using a gait belt. Where should the nurse position the gait belt?

Answer: Around the client's waist, over clothing

The gait belt is correctly placed around the client's waist over clothing to provide a secure grip without restricting breathing.

A nurse is caring for a client with a wound drain (Jackson-Pratt). The nurse notes the bulb is fully expanded. What is the correct nursing action?

Answer: Empty and recompress the bulb to re-establish suction

A fully expanded Jackson-Pratt bulb means suction has been lost; the nurse must empty the collected drainage and compress the bulb to restore negative pressure.

A nurse is caring for an older adult client who refuses to eat the hospital meal. Which response by the nurse best supports the client's autonomy while addressing nutritional needs?

Answer: Ask the client about food preferences and involve a dietitian to offer alternatives

Exploring the client's food preferences and collaborating with a dietitian respects autonomy while actively addressing the nutritional deficit.

A nurse is caring for a client who has been on bed rest for five days. The client reports calf pain and swelling. Which action should the nurse take first?

Answer: Immobilize the limb, discontinue ambulation, and notify the physician immediately

Calf pain and swelling in an immobile client suggest deep vein thrombosis; ambulation must stop immediately and the physician must be notified to prevent pulmonary embolism.