Foundations 310 Practice Exam A

A nurse is caring for a client who has fallen while getting out of bed ... Which of the following documentation should the nurse include in the client's medical record? -"There were no injuries sustained." -"An incident report was completed." -"An incident report was forwarded to risk management." -"The provider was notified."

-"The provider was notified." (Nursing interventions that support factual information should be documented in the health record.)

A nurse is caring for a client who needs a stool specimen collected. Which of the following actions should the nurse take when obtaining the specimen? -use a sterile swab to obtain the specimen -place the specimen in a sterile container -label the paper bag in which specimen container is placed -send specimen container immediately to the lab

-send specimen container immediately to the lab (The nurse should label the specimen contain and send it immediately to the laboratory. A delay in transport can result in altered laboratory findings.)

A nurse is discussing the norming stage of the group development process with a student nurse. Which of the following statements by the student indicates an understanding of the discussion? -"This stage involves constructive efforts on the part of the group members." -"This stage is when testing occurs to identify boundaries of interpersonal behaviors." -"Consensus evolves in this stage." -"Resistance is evident as subgroups for in this stage."

-"Consensus occurs in this stage." (Consensus occurs and cooperation develops during the norming stage of the group development process.)

A nurse is orienting a newly licensed nurse about documentation of a client's information in the electronic health record. Which of the following statements by the newly licensed nurse indicates understanding of the purpose of documentation? -"Documentation is a communication tool for the interprofessional health care team." -"Documentation provides information to he client about financial charges for care provided." -"Documentation provides information for a client audit." -"Documentation allows providers to monitor the nurse's activities."

-"Documentation is a communication tool for the interprofessional health care team." (Documentation provides information to facilitate communication among members of the interprofessional health care team in making client-centered decisions, planning appropriate therapies and evaluating a client's progress.)

A nurse at an extended-care facility is instructing a class of APs about client use of assistive devices during ambulation. Which of the following instructions should the nurse give the APs about the clients' use of a cane? -"When the client moves, he should move the cane forward first." -"The client should hold the cane in the weak side of his body." -"The grip should be at the client's waist" -"The client should first move the strong leg forward ahead of the cane and the weak leg."

-"When the client moves, he should move the cane forward first." (When the client moves, he should first move the cane forward about 30.5 cm (12 in). Then, he should move the weak leg even with the cane. Finally, he should bring the strong leg forward and ahead of the cane and his weak leg.)

A nurse enters an older client's room to insert a saline lock. The client asks the nurse, "Why do I need that? I am drinking plenty of fluids." Which of the following responses should the nurse provide? -"It is quicker to administer medications intravenously in the hospital." -Clients over the age of 65 must have a saline lock according to facility policy." -"We administer all medications intravenously to clients in this unit." -"Your provider has prescribed antibiotic therapy to be administered intravenously every 6 hours."

-"Your provider has prescribed antibiotic therapy to be administered intravenously every 6 hours." (Intermittent antibiotic medications are frequently administered parenterally. This allows the client to ambulate between medication administrations, enhances client safety and promotes comfort. The response addresses the client's concern.)

A nurse is assessing a client who is experiencing prostatic hypertrophy. Which of the following findings associated with urinary retention should the nurse expect? (Select all that apply.) -report of feeling pressure -tenderness over symphysis pubis -distended bladder -voiding 30mL frequently -dysuria

-Report of feeling pressure (Urinary retention is commonly seen in clients diagnosed with prostatic hypertrophy. Clinical findings of urinary retention include a report of feeling pressure.) -Tenderness over the symphysis pubis (Urinary retention is commonly seen in clients diagnosed with prostatic hypertrophy. Clinical findings of urinary retention include tenderness over the symphysis pubis.) -Distended bladder (Urinary retention is commonly seen in clients diagnosed with prostatic hypertrophy. Clinical findings of urinary retention include a distended bladder.) -Voiding 30 mL frequently (Urinary retention is commonly seen in clients diagnosed with prostatic hypertrophy. Clinical findings of urinary retention include frequent voiding of 25 to 60 mL of urine.)

A nurse is admitting a client who reports anorexia and is experiencing malnutrition. Which of the following laboratory findings should the nurse expect to be altered? -creatine kinase -troponin -total bilirubin -albumin

-albumin (A low albumin is a measure of plasma proteins which reflects the nutritional condition of a client experiencing anorexia and malnutrition over an extended period of time.)

A nurse is ready to insert an indwelling urinary catheter for a female client. Which of the following instructions should the nurse give the client as the catheter is inserted? -contract the pelvic muscles -take a sip of water -exhale slowly -bear down

-bear down (Bearing down gently as if to void relaxes the external sphincter and eases urinary catheter insertion.)

A nurse is providing discharge teaching about clean intermittent self-catheterization for a client who has benign prostatic hyperplasia. Which of the following instructions should the nurse include? -perform catheterization when you recognize the urge to void -hold the penis at a 30 to 45 degree angle when inserting the catheter -inflate the balloon when the urine flow stops -use soap and water to wash the catheter after each use

-use soap and water to wash the catheter after each use (The client should perform clean intermittent self-catheterization on a schedule, typically every 2 to 3 hr at first and increasing to every 4 to 6 hr. The client should attempt to urinate prior to performing the procedure.) (The client should hold the penis at a 60° to 90° angle when inserting the catheter.) (The client should perform a clean intermittent self-catheterization with a single lumen catheter that does not have a balloon. The client should hold the catheter in place until all urine drains, and then slowly remove the catheter.)

A nurse is caring for a client who is scheduled for an elective surgical procedure. Which of the following actions should the nurse take regarding informed consent? -obtain the clients consent -witness the client's signature -explain the risks and benefits of the procedure -explain the procedure to the client if they do not understand

-witness the client's signature (It is the nurse's responsibility to witness the client's signing of the consent form, and to verify that the client is consenting voluntarily and appears to be competent to do so.)

A nurse is administering nasal decongestant drops for a client. Which of the following actions should the nurse take? -tell the client to blow her nose gently before the instillation -assist the client to a side-lying position -hold the dropper 2 cm (1 in) above the naris -instruct the client to stay in the same position for 2 min

-tell the client to blow her nose gently before the instillation (Prior to instillation, the nurse should instruct the client to blow her nose gently. This action will help remove any secretions or crusts that could interfere with the distribution and absorption of the medication.)

A nurse is caring for four clients who have drainage tubes. Which of the following clients should the nurse recognize as being at risk for hypokalemia? -the client who has a tracheostomy tube attached to humidified oxygen -the client who has an indwelling urinary catheter to gravity drainage -the client who has a chest tube to water seal -the client who has a NG tube to suction

-the client who has a NG tube to suction (Hypokalemia is a low serum potassium value. An NG tube is used to decompress the stomach. When attached to suction, an NG tube will remove gastric contents, which are high in electrolytes, especially potassium, and this loss places the client at risk for hypokalemia.)

A nurse is reviewing information about the Health Insurance Portability and Accountability Act (HIPAA) with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates a need for further teaching? -"Information about a client can be disclosed to family members at any time." -"HIPAA established regulations of individually identifiable health information in verbal, electronic, or written form." -"A client's address would be an example of personally identifiable information." -"HIPAA is a federal law, not a state law."

-"Information about a client can be disclosed to family members at any time." (This statement reflects a need for further teaching. Privacy relates to the client's rights over the use and disclosure of his or her own personal health information.)

A nurse is caring for a client who has a prescription for a stool test for guaiac. The nurse understands the purpose of the test is to check the stool for which of the following substances? -steatorrhea -blood -bacteria -parasites

-blood (A guaiac test detects the presence of occult or hidden blood in the stool. The guaiac test is an extremely useful diagnostic screening test for the presence of colon cancer and gastrointestinal ulcers.)

A nurse is assessing for cyanosis in a client who has dark skin. Which of the following sites should the nurse examine to identify cyanosis in this client? -pinnae of the ears -dorsal surface of the hand -conjunctivae -dorsal surface of the foot

-conjunctivae (To assess skin color changes in clients who have dark skin, the nurse should examine body areas with minimal pigmentation, such as the sclerae, soles of the feet, conjunctivae, and mucous membranes.)

A nurse is working with a team of nursing personnel w/in a facility. Which of the following are necessary task performance roles that members of the group or the leader must perform? (Select all that apply.) -self-confessor -coordinator -evaluator -energizer -dominator

-coordinator (Coordinator is a task performance role that focuses on clarification and coordination of ideas.) -evaluator (Evaluator is a task performance role that focuses on comparing group accomplishments with expected standards.) -energizer (Energizer is a task performance role that focuses on stimulating the group to higher levels of action.)

A nurse is planning care for a client who has a decreased level of consciousness. The client is receiving continuous enteral feedings via a gastrostomy tube due to an inability to swallow. Which of the following is the priority action by the nurse? -observe the client's respiratory status -elevate the head of the client's bed 30 to 45 degrees -monitor intake and output every 8 hrs -check residual vol every 4 to 6 hours

-elevate the head of the client's bed 30 to 45 degrees (A client who has a decreased level of consciousness and an inability to swallow is at risk for aspiration. Lying flat also increases this risk. The priority action by the nurse is to keep the head of the bed elevated 30 to 45 degrees to promote gastric emptying and reduce the risk of aspiration.)

A nurse is caring for a client who has impaired mobility. Which of the following support devices should the nurse plan to use to prevent the client from developing plantar flexion contractures? -trochanter roll -sheepskin heel pad -abduction pillow -footboard

-footboard (Plantar flexion contractures, or foot drop, develop when a client's unsupported feet are constantly in plantar flexion. The nurse should place the soles of the client's feet against a footboard, a flat wooden or plastic panel perpendicular to the bed, to keep them dorsiflexed and, therefore, prevent foot drop.)

A nurse is assisting an older adult client who sometimes loses her balance while walking. Which of the following devices should the nurse use when helping the client ambulate? -gait belt -jacket harness -four-wheel walker -cane

-gait belt (The nurse should use a gait belt to help support the client during ambulation. A gait belt helps keep the client's center of gravity stable and helps maintain balance and prevent falls.)

A nurse is providing preoperative teaching by demonstrating diaphragmatic breathing to a client who is scheduled for surgery in the morning. Which of the following actions should the nurse include in the demonstration? -place her hands on the sides of her rib cage -inhale slowly and evenly through her nose -hold her breath for at least 10 seconds -exhale forcefully through the nose

-inhale slowly and evenly through her nose (The nurse should place her hands palms down on the border of her rib cage. The nurse should inhale slowly and evenly through her nose until chest expansion is maximized. The nurse should hold her breath for 2 to 3 seconds. The nurse should exhale slowly through the mouth.)

A client smoking in his bathroom has dropped a cigarette butt into a wastepaper basket, which begins to smolder. Which of the following actions is the nurse's priority? -close the fire doors on the unit -activate the fire alarm -move any clients in the immediate vicinity -use a fire extinguisher to put out the fire

-move any clients in the immediate vicinity (The greatest risk to clients is injury from smoke and fire; therefore, the nurse's first action is to move any clients near the smoke to a safe location. The acronym RACE is a reminder of the order in which to take steps in the event of a fire. The nurse should rescue the clients, activate the fire alarm, confine the fire, and extinguish the fire.)

A nurse is providing care to a client who is on strict bed rest following surgery. The nurse assists the pt to the bedside commode and the client sustains an injury to the operative area. Which of the following types of torts has the nurse committed? -battery -negligence -malpractice -assault

-negligence (Negligence is the failure to provide the expected standard of care. The expected standard of care was strict bedrest.)

A nurse has completed an informed consent form with a client. The client states, "I have changed my mind and do not want to have the procedure done." Which of the following actions should the nurse take? -remind the client that a signed consent form is a legally binding document -notify the surgeon that the client wishes the withdraw informed consent for the procedure -inform the surgical team to cancel the client's surgery -proceed with preparation of the patient for the surgical procedure

-notify the surgeon that the client wishes the withdraw informed consent for the procedure (The client has the right to withdraw informed consent; therefore, the surgeon who is the one to obtain the informed consent should be notified of the request.)