Exam 1 - Fundamentals of Nursing Didactic
A nurse is beginning to complete a bed bath. After removing the client's gown and placing a bath blanket over him, which of the following should the nurse was first? A) Face B) Feet C) Chest D) Arms
A
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 the fall-risk assessment B)Educate the client and family about fall risk C) Eliminate safety hazards from the client's environment D) Make sure the client uses assistive devices
A
A nurse is discussing the nursing process with a newly hired nurse. Which of the following statements by the new nurse should the nurse identify for the planning step of the nursing process? A) I will determine the most important client problem that we should address B) I will review the past medical hx on the client's record to get more info. C) I will go carry out the new prescription from the provider D) I will ask the client if his nausea has resovled
A
A nurse is performing oral care for a client who is unconscious. Which of the following actions should the nurse take? A) Turn the client's head to the side. B) Place two fingers in the client's mouth to open. C) Brush the client's teeth once per day D) Inject a mouth rinse into the center of the client's mouth
A
A nurse is planning care for a client who develops dyspnea and feels tired after completing her AM care. Which of the following actions should the nurse include in plan of care? A) Schedule rest periods during her AM routine B) Discontinue morning care for 2 days C) Perform all care as quickly as possible D) Ask a family member to come in to bathe the client
A
A nurse is caring for a client who is postoperative. Which of the following interventions should the nurse take to reduce the risk of thrombus development? (AKA clots) *Select all that apply* A) Instruct the patient to not perform the Valsalva maneuver. B) Apply elastic stockings. C) Review laboratory values for total protein level D) Place pillows under the client's knees and lower extremities E) Assist the client to change position often
A & E.
A nurse is planning care for a client who is on bed rest. Which of the following interventions should the nurse plan to implement? A) Encourage the client to perform antiembolic exercises every 2 hours. B) Instruct the client to cough and deep breathe every 4 hours. C) Restrict the client's fluid intake D) Re position the client every 4 hours
A) Encourage the client to perform antiembolic exercises every 2 hours.
A client becomes dizzy while ambulating with a nurse for the first time after surgery and starts falling forward. Which action should the nurse take first? A) Widen his or her stance B) Pull up on the client's arm C)Tighten the grip on the gait belt D) Have the client look at the floor
A) Widen his or her stance
A nurse is instructing a patient who has diabetes mellitus about foot care. Which of the following guidelines should the nurse include? *Select all that apply A) Inspect the feet daily B) Use moisturizing lotion on the feet C) Wash the feet with warm water and let them air dry D) Use OTC products to treat abrasions E) Wear cotton socks
A, B, &
A charge nurse is reviewing the steps of the nursing process with a group of nurses. Which of the following should the charge nurse identify as objective data? *Select all that apply A. Respiratory rate is 22/min with even, unlabored resp. B) The client's partner states "He said he hurts after walking about 10 minutes" C) Pain rating is a 3 on a scaled of 0 to 10 D) Skin is pink, warm, and dry E) The assistive personnel reports the client walked with a limp
A, D, & E
A nurse is instructing a client, who has an injury of L. lower extremity,about the use of a cane. Which of the following instructions should the nurse include? *Select all that apply* A)Hold the cane on the right side B) Keep two points of support on the floor C) Place the can 38 in(15 in) in front of the feet before advancing D)After advancing the cane, move the weaker leg forward E) Advance the stronger leg so that it aligns evenly with the cane
A,B, &D
A newly licensed nurse is reporting to the charge nurse about the care she gave to a client. She states, "The client said his leg pain was back, so I checked his medical record, and he last received his pain medication 6 hours ago. The prescription reads every 4 hours PRN for pain, so I decided he needs it. I asked the unit nurse to observe me preparing and administering it. I checked with the client 40 minutes later, and he said his pain is going away." The charge nurse should inform the newly licensed nurse that she left out which of the following steps of the nursing process? A. Assessment B. Planning C. Intervention D. Evaluation
A.
By 2nd post-op day, a client has not achieved satisfactory pain relief. Based on this evaluation, what should nurse do next according to nursing process? A: Reassess client to determine reasons for unsatisfactory pain relief B: See whether pain lessens during next 24h C: Change plan to ensure client achieves adequate pain relief D: Teach client about plan of care for managing his pain
A.
Which patients require standard precautions?
ALL PATIENTS
What is a negative air flow room for?
Airborne precautions
What is the acronym ADPIE mean?
Assessment Diagnosis Planning Implementing Evaluation
A nurse is preparing to perform denture care for a client. Which of the following actions should the nurse plan to take? A) Pull down and out at the back of the upper denture to remove B) Brush the dentures with a toothbrush and denture cleaner. C) Rinse the dentures with hot water after cleaning them D) Place the dentures in a clean, dry storage container after cleaning them
B
A nurse manager is reviewing with nurses of a client who has had a seizure. Which of the following statements by a nurse requires further instruction? A) I will place the client on his side. B) I will go to the nurses station for assistance C) I will administer his medications D) I will prepare to insert an airway
B
A nurse is caring for a client whose head of the bed is elevated 65 degrees and knees are slightly elevated. Which position should the nurse appropriately chart for the patient? A) Sims' B) High fowlers C) Supine D) Fowlers
B) Fowlers
A client with right leg weakness is prescribed to use a walker. Which direction should the nurse provide when instructing on the use of this device? A) Move the walker ahead of the right foot B) Move the right foot and the walker together C) Move the right foot up to the walker first D) Move the left foot and the walker together
B) Move the right foot and the walker together
A nurse observes smoke coming from under the door of the breakroom. Which of the following actions should the nurse take? A) Extinguish the fire B) Activate the fire alarm C) Move the patients that are nearby D) Close all the open doors on the unit
C
What is NOT an example of a NANDA diagnosis? A) Constipation B) Ineffective gas exchange C) COPD exacerbation D) Risk for infection
C) COPD exacerbation
A nurse is providing teaching to a client who is newly diagnosed with osteoarthritis. Which response by the client requires further teaching? A) Acetaminophen or ibuprofen may help my pain. B) I should remove loose rugs in my house. C) I should remain in bed until my arthritis pain is gone. D) I can apply a cold compress to help with the pain.
C) I should remain in bed until my arthritis pain is gone.
A nurse is caring for a client who has been sitting in a chair for 1 hour. Which of the following complications is the greatest risk to the client? A) Decreased subcutaneous fat B) Muscle atrophy C) Pressure ulcer D) Fecal impactation
C) Pressure ulcer
The nurse prepares to provide oral care to a 20-month-old client. Which action should the nurse take when completing this care? A) Lower the head of the bed B) Place the client in a side-lying position C) Use a soft-bristled toothbrush moistened with water D) Use a syringe to apply mouthwash to the oral cavity
C) Use a soft-bristled toothbrush moistened with water
A charge nurse is talking with a newly licensed nurse and reviewing the interventions that do not require a provider's orders. Which of the following interventions should the charge nurse include? *Select all that apply* A) Writing a prescription for morphine sulfate prn B) Insterting a NG tube to relieve gastric distention C) Showing a client how to use progressive muscle relaxtion D) Performing a daily bath after the evening meal E) Repositioning a client every 2 hours to reduce the pressure ulcer risk
C, D, & E
A nurse is caring for a client who fell at home. The client is orientated to person, place, and time and can follow directions. Which of the following should the nurse take to decrease the risk of another fall? *Select all that apply A) Place a belt restraint on the client while he is sitting on the bedside commode B) Keep the bed in its lowest position with all the 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, D, & E
What is a disease process that requires contact precautions?
C. diff
What occurs during the "Evaluate" phase of ADPIE?
Check to see if patient has met planned out goals If patient has not met the goals, reassessment has to occur and new goals need to be made
What is occuring during the "Assessment" phase of ADPIE?
Collecting patient data (subjective and objective) Vital signs Chief complaint for visit Other forms of assessment (Ex. heart and lung assessment)
A charge nurse is assigning rooms for clients to be admitted. To prevent falls, which of the following room should the nurse assign closest to the nurses station? A) Middle age adult who is postoperative following a laparoscopic cholecystemotomy B) Middle adult who requires telemetry for a possible myocardial infarction C) Young adult who is posteroperative following an open reduction internal fiaxtion of the ankle D) Older adult who is postop following a below-the-knee amoutation
D
Which of these goals follow the SMART acronym? A) The patient will not be in pain. B) The patient will walk by 1800. C) The patient will walk 20 feet. D) The patient will walk 20 feet by 1800.
D) The patient will walk 20 feet by 1800.
What is occuring during the "Planning" phase of ADPIE?
Formulating short and long term goals for the patient (SMART goals)
What are some disease processes that require droplet precautions?
Influenza virus
What are some disease processes that require airborne precautions?
Measles, tuberculosis
What is occuring in the "Diagnosis" phase of ADPIE?
Nursing diagnosis is made during assessment (NANDA) NOT A MEDICAL DIAGNOSIS
What are some fall preventions?
Place tables and call light near in patient's reach Nonskid footwear Purposeful rounding Tidy environment
What does the acronym SMART goals mean?
Specific Measureable Attainable Relevant Timeframe
What is ADPIE used for?
The nursing process