Fundamentals 1

A nurse is reinforcing preoperative teaching with a client who is scheduled for arthroplasty is the next month and might require a blood transfusion. The client expresses concern about the risk of acquiring an infection from the blood transfusion. Which of the follow suggestions should the nurse make?

"Donate autologous blood before the surgery."

A nurse in an oncology clinic is collecting data for a client who is undergoing treatment for ovarian cancer. Which of the following statements by the client indicates she is experiencing psychological distress?

"I keep having nightmares about my upcoming surgery."

A nurse is reinforcing teaching with a group of older adults about expected changes of aging. Which of the following statements by a group member indicates that the teaching has been effective?

"I should expect my heart rate to take longer to return to normal after exercise as I get older".

A nurse is reinforcing teaching with an older adult client who has constipation. Which of the following statements should the nurse include in the teaching?

"Sit on the toilet 30 minutes after eating a meal"

A nurse is caring for a client who has type 1 diabetes mellitus and is resistant to learning self-injection of insulin. Which of the following statements should the nurse make?

"Tell me what I can do to help you overcome your fear of giving yourself injections".

A nurse is instructing an assistive personnel (AP) about proper hand hygiene. Which of the following statements by the AP indicates an understanding of the teaching?

"There are times I should use soap and water rather than an alcohol-based hand rub to clean my hands."

A nurse observes an assistive personnel (AP) preparing to obtain blood pressure with a regular-size cuff for a client who is obese. Which of the following explanations should the nurse give the AP?

"Using a cuff that is too small will result in an inaccurately high reading".

A nurse is caring for an older adult client who becomes agitated when the nurse requests that the client's dentures be removed prior to surgery. Which of the following responses should the nurse make?

"What worries you about being without your teeth?"

A nurse is collecting data for an adult client. Identify the correct sequence of steps used for data collection of the abdomen.

1. Inspection 2. Palpation 3. Percussion 4. Auscultation

A nurse is collecting data for the health history of a client who is postoperative and has paralytic ileum. Which of the following findings should the nurse expect?

Absent bowel sounds with distention

A nurse is caring for a child who is postoperative following a tonsillectomy. Which of the following actions should the nurse take?

Administer analgesics to the child on a routine schedule throughout the day and night.

A nurse is planning weight loss strategies for a group of clients who are obese. Which of the following actions by the nurse will improve the clients' commitment to a long term goal of weight loss?

Attempt to increase the clients' self-motivation

A nurse is drawing blood for laboratory testing from a client that results in a blood spill on her gloved hand. The client has no documented bloodstream infection. Which of the following actions should the nurse take?

Carefully remove the gloves and follow with hand hygiene

A nurse is reviewing adult cardiopulmonary resuscitation (CPR) with a newly licensed nurse. Which of the following steps should the nurse identify as the first response when preforming CPR?

Confirm unreponsiveness

A nurse is measuring vital signs for a client and notices as irregularity in the pulse. Which of the following actions should the nurse take?

Count the apical pulse rate for 1 full minute, and describe the rhythm in the chart.

A nurse on a medical surgical unit is admitting a client. Which of the following information should the nurse document in the client's record first?

Data collection for the client.

A nurse is caring for a client who is unstable and has vital signs measured every 15 minutes by an electronic blood pressure machine. The nurse notices the machine begins to measure the blood pressure at varied intervals and the readings are inconsistent. Which of the following actions should the nurse take?

Disconnect the machine and measure the blood pressure manually every 15 minutes.

A nurse is caring for a client who has a terminal illness. The client asks several questions about the nurse's religious beliefs related to death and dying. Which of the following actions should the nurse take?

Encourage the client to express his thoughts about death and dying.

A nurse is collecting data for a client who has decreased circulation in his left leg. Which of the following actions should the nurse take first?

Evaluate pedal pulses

A nurse is collecting data for a client who has had diarrhea and decreased urination for several days. Which of the following action should the nurse take to determine if the client is dehydrated?

Grasp a skin fold on the best under the clavicle, release it, and note whether it springs back.

A nurse is caring for a client who requires a chest x-ray. Prior to the client being transported for the procedure, which of the following actions should the nurse take first?

Identify the client using two identifiers

A nurse is receiving a client from the PACU who is postoperative following abdominal surgery. Which of the following actions should the nurse take to transfer the client from the stretcher to the bed?

Lock the wheels on the bed and stretcher.

A nurse is preparing a client who is scheduled for a hysterectomy for transport to the operating room when the client states she no longer wants to have the surgery. Which of the following actions should the nurse take?

Notify the provider about the client's decision.

A nurse on a medical-surgical unit is caring for a client. Which of the following actions should the nurse take first when using the nursing process?

Obtain client information

A charge nurse is observing a newly licensed nurse perform tracheostomy care for a client. Which of the following actions by the newly licensed nurse requires interventions?

Obtaining cotton balls for the tracheostomy care

A nurse is preparing to provide tracheostomy care for a client. Which of the following actions should the nurse take first?

Perform hand hygiene.

A nurse is auscultating the heart sounds of a client who has developed chest pain that worsens with inspiration. The nurse hears a high-pitched scratching sound with the diaphragm of the stethoscope placed at the third intercostal space of the left sternal border. Which of the following heart sounds should the nurse document?

Pericardial friction rub

A nurse is obtain the blood pressure in a client's lower extremity. Which of the following actions should the nurse take?

Place the bladder of the cuff over the posterior aspect of the thigh.

A nurse on a rehabilitation unit is preparing to transfer a client who is unable to walk from a bed to a wheelchair. Which of the following techniques should the nurse use?

Place the wheelchair at a 45 degree angle to the bed.

A nurse is preparing to perform oral care for a client who is unresponsive. Which of the following actions should the nurse plan to take?

Raise the level of the bed.

A nurse is caring for an older adult client who is violent and attempting to disconnect her IV lines. The provider prescribes soft wrist restraints.Which of the following actions should the nurse take while the client is restraints?

Remove the restraints one at a time.

A nurse is assisting with planning a community about seasonal influenza. Which of the following plans should be included as a secondary prevention strategy?

Screening groups of older adults in nursing care facilities for early influenza manifestations.

A nurse at a screening clinic is collecting data for a client who reports a history of a heart murmur related to aortic valve stenosis. At which of the following anatomical areas should the nurse place the stethoscope to auscultate the aortic valve?

Second intercostal space to the right of the sternum

A nurse is caring for a client who is in the terminal stage of cancer. Which of the following actions should the nurse take when she observes the client crying?

Sit and hold client's hand.

A nurse is collecting data from a client who reports abdominal pain. Further findings reveal the client has a temperature of 39.2 C (102.6 F), a heart rate of 105/min, a soft intender abdomen, and menses overdue by 2 days. Which of the following findings should be the nurse's priority?

Temperature

A nurse is planning to obtain the vital signs of a 2-year-old child who is experiencing diarrhea and who may have a right ear infection. Which of the following routes should the nurse use to obtain the temperature?

Temporal

A nurse is reinforcing teaching with a client who has heart failure about how to reduce his daily intake of sodium. Which of the following factors is the most important in determining the client's ability to learn new dietary habits?

The involvement of the client in planning the change.

A nurse on a medical-surgical unit is washing her hands prior to assisting with a surgical procedure. Which of the following actions by the nurse demonstrates proper surgical hand-washing technique?

The nurse washes with her hands held higher than her elbows.

A nurse is witnessing a client signing an informed consent form for surgery. Which of the following describes what the nurse is affirming by this action?

The signature on the preoperative consent form is the client's.

A nurse is reinforcing teaching of postoperative deep breathing and coughing exercises with a client who will have emergency surgery for appendicitis. Which statement indicates a lack of readiness to learn by the client?

A client who is experiencing severe pain is not able to concentrate and therefore is not ready to learn a new activity.