Fundamentals

A nurse is performing an admission assessment on a client. The nurse determines the client's radial pulse rate is 68/min and the simultaneous apical pulse rate is 84/min. What is the client's pulse deficit?

16/min

A nurse is instructing an assistive personnel (AP) about caring for a client who has a low platelet count as a result of chemotherapy. Which of the following instructions is the priority for measuring vital signs for this client? A. "Do not measure the client's temperature rectally." B. "Count the client's radial pulse for 30 seconds and multiple it by 2." C. "Do not let the client know you are counting her respirations. D. "Let the client rest for 5 minutes before you measure her blood pressure.

A. "Do not measure the client's temperature rectally."

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 a fall-risk assessment. B. Educate the clients and family about fall risks. C. Eliminate safety hazards from the client's environment. D. Make sure the client uses assistive aids in his possession.

A. Complete a fall-risk assessment.

A client who had abdominal surgery 24 hr ago suddenly reports a pulling sensation and pain in his surgical incision. The nurse checks the surgical wound and finds it separated with viscera protruding. Which of the following actions should the nurse take? (Select all that apply.) A. Cover the area with saline-soaked sterile dressings. B. Apply an abdominal binder snugly around the abdomen. C. Use sterile gauze to apply gentle pressure to the exposed tissue. D. Position the client supine with his hips and knees bent. E. Offer the client a warm beverage, such as herbal tea.

A. Cover the area with saline-soaked sterile dressings. D. Position the client supine with his hips and knees bent.

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 hr. B. Instruct the client to cough and deep breathe every 4 hr. C. Restrict the client's fluid intake. D. Reposition the client every 4 hr.

A. Encourage the client to perform antiembolic exercises every 2 hr.

A nurse is beginning a complete bed bath for a client. After removing the client's gown and placing a bath blanket over him, which of the following areas should the nurse wash first? A. Face B. Feet C. Chest D. Arms

A. Face

A nurse educator is reviewing with a newly hired nurse the difference in manifestations of a localized versus a systemic infection. The nurse indicates understanding when she states that which of the following are manifestations of a systemic infection? (Select all that apply.) A. Fever B. Malasia C. Edema D. Pain or tenderness E. Increase in pulse and respiratory rate

A. Fever B. Malasia E. Increase in pulse and respiratory rate

A nurse is instructing a client, who has an injury of the left 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 cane 38 cm (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. Hold the cane on the right side. B. Keep two points of support on the floor. D. After advancing the cane, move the weaker leg forward.

A nurse educator is presenting a module on basic first aid for newly licensed home health nurses. The nurse educator evaluates the teaching as effective when the newly licensed nurse states the client who has heat stroke will have which of the following. A. Hypotension B. Bradycardia C. Clammy skin D. Bradypnea

A. Hypotension

A nurse is collecting data from a client who is 5 days postoperative following abdominal surgery. The surgeon suspects an incisional wound infection and has prescribed antibiotic therapy for the nurse to initiate after collecting wound and blood specimens for culture and sensitivity. Which of the following findings should the nurse expect? (Select all that apply.) A. Increase in incisional pain B. Fever and chills C. Reddened wound edges D. Increase in serosanguineous drainage E. Decrease in thrist

A. Increase in incisional pain B. Fever and chills C. Reddened wound edges

A nurse is instructing a client 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. Washing the feet with warm water and let them air dry. D. Use over-the-counter products to treat abrasions. E. Wear cotton socks.

A. Inspect the feet daily. B. Use moisturizing lotion on the feet. E. Wear cotton socks.

A nurse is caring for an older adult client who is at risk for developing pressure ulcers. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin? (Select all that apply.) A. Keep the head of the bed elevated 30°. B. Massage the client's bony prominences frequently. C. Apply cornstarch liberally to the skin after bathing. D. Have the client sit on a gel cushion when in a chair. E. Reposition the client at least every 3 hr while in bed.

A. Keep the head of the bed elevated 30°. D. Have the client sit on a gel cushion when in a chair.

A nurse is caring for an 82-year-old client in the emergency department who has an oral body temperature of 38.3° C (101° F), pulse rate 114/min, and respiratory rate 22/min. He is restless and his skin is warm. Which of the following interventions should the nurse take? (Select all that apply.) A. Obtain culture specimens before initiating antimicrobials. B. Restrict the client's oral fluid intake. C. Encourage the client to rest and limit activity. D. Allow the client to shiver to dispel excess heat. E. Assist the client with oral hygiene frequently.

A. Obtain culture specimens before initiating antimicrobials. C. Encourage the client to rest and limit activity. E. Assist the client with oral hygiene frequently.

A nurse is instructing a group of nursing students in measuring a client's respiratory rate. Which of the following guidelines should the nurse include? (Select all that apply.) A. Place the client in semi-Fowler's position. B. Have the client rest an arm across the abdomen. C. Observe one full respiratory cycle before counting the rate. D. Count the rate for 30 seconds if it is irregular. E. Count and report any signs the client demonstrates.

A. Place the client in semi-Fowler's position. B. Have the client rest an arm across the abdomen. C. Observe one full respiratory cycle before counting the rate.

A nurse is caring for a client diagnosed with severe acute respiratory syndrome (SARS). The nurse is aware that health care professionals are required to report communicable and infectious diseases. Which of the following illustrate the rationale for reporting? (Select all that apply.) A. Planning and evaluating control and prevention strategies. B. Determining public health priorities. C. Ensuring proper medical treatment. D. Identifying endemic disease. E. Monitoring for common-source outbreaks.

A. Planning and evaluating control and prevention strategies. B. Determining public health priorities. C. Ensuring proper medical treatment. E. Monitoring for common-source outbreaks.

A nurse is planning care for a client who develops dyspnea and feels tired after completing her morning care. Which of the following actions should the nurse include in the client's plan of care? A. Schedule rest periods during morning care. 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. Schedule rest periods during morning care.

A nurse is performing mouth 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. Turn the client's head to the side.

A nurse educator is reviewing the wound healing process with a group of nurses. The nurse educator should include in the information which of the following alterations for wound healing by secondary intention? (Select all that apply.) A.Stage III pressure ulcer B. Sutured surgical incision C. Casted bone fracture D. Laceration sealed with adhesive E. Open burn area

A.Stage III pressure ulcer E. Open burn area

A nurse manager is reviewing with nurses on the unit the care of a client who has had 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. "I will go to the nurses' station for assistance."

A nurse is evaluating teaching on a client who has a new prescription for a sequential compression device. Which of the following clients statements should indicate to the nurse the client understands the teaching? A. "This device will keep me form getting sores on my skin." B. "This thing will keep the blood pumping through my leg." C. "With this thing on, my leg muscles won't get weak." D. "This device is going to keep my joints in good shape."

B. "This thing will keep the blood pumping through my leg."

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? (Select all that apply.) A. Instruct the client not to 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.

B. Apply elastic stockings. E. Assist the client to change position often.

A nurse who is admitting a client who has a fractured femur obtains a blood pressure reading of 140/94 mmHg. The client denies any history of hypertension. Which of the following actions should the nurse take first? A. Request a prescription for an antihypertensive medication. B. Ask the client if she is having pain. C. Request a prescription for an antianxiety medication. D. Return in 30 min to recheck the client's blood pressure.

B. Ask the client if she is having pain.

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. Brush the dentures with a toothbrush and denture cleaner.

A home health nurse is discussing the dangers of food poisoning with a client. Which of the following information should the nurse including in her counseling? (Select all that apply.) A. Most food poisoning is caused by a virus. B. Immunocompromised individuals are at risk for complications form food poisoning. C. Clients who are at high risk should eat or drink only. D. Healthy individuals usually recover from the illness in a few weeks. E. Handling raw and fresh food separately can prevent food poisoning.

B. Immunocompromised individuals are at risk for complications form food poisoning. C. Clients who are at high risk should eat or drink only. E. Handling raw and fresh food separately can prevent food poisoning.

A nurse is caring for an adolescent client who is 2 days postoperative following an appendectomy and has type I diabetes mellitus. The client is tolerating a regular diet. He has ambulated successfully around the unit with assistance. He requests pain medication every 6 to 8 hr while reporting pain at a 2 on the scale of 0 to 10 after receiving the medication. His incision is approximated and free of redness, with scant serous drainage on the dressing. The nurse should recognize that the client has which of the following risk factors for impaired wound healing? (Select all that apply.) A. Extremes in age B. Impaired circulation C. Impaired/suppressed immune system D. Malnutrition E. Poor wound care

B. Impaired circulation C. Impaired/suppressed immune system

A nurse is providing discharge instructions to a client who has a prescription for oxygen use at home. Which of the following information should the nurse include about home oxygen safety? (Select all that apply.) A. Family members who smoke must be at least 10 ft from the client when oxygen is in use. B. Nail polish should not be used near a client who is receiving oxygen. C. A "No Smoking" sign should be placed on the front door. D. Cotton bedding and clothing should be replaced with items made from wool. E. A fire extinguisher should be readily available in the home.

B. Nail polish should not be used near a client who is receiving oxygen. C. A "No Smoking" sign should be placed on the front door. E. A fire extinguisher should be readily available in the home.

A nurse has prepared a sterile field for assisting a provider with a chest tube insertion. Which of the following events should the nurse recognize as contaminating the sterile field? (Select all that apply.) A. The provider drops a sterile instrument onto the near side of the sterile field. B. The nurse moistens a cotton ball with sterile normal saline and places it on the sterile field. C. The procedure is delayed 1 hr because the provider receives an emergency call. D. The nurse turns to speak to someone who enters through the door behind the nurse. E. The client's hand brushes against the outer edge of the sterile field.

B. The nurse moistens a cotton ball with sterile normal saline and places it on the sterile field. C. The procedure is delayed 1 hr because the provider receives an emergency call. D. The nurse turns to speak to someone who enters through the door behind the nurse.

A nurse is reviewing hygiene techniques with a group of assistive personnel (AP). Which of the following instructions should the nurse include when discussing handwashing? (Select all that apply.) A. Apply 3 to 5 mL of liquid soap to dry hands. B. Wash the hands with soap and water for at least 15 seconds. C. Rinse the hands with hot water. D. Use a clean paper towel to turn off hand faucets. E. Allow the hands to air dry after washing.

B. Wash the hands with soap and water for at least 15 seconds. D. Use a clean paper towel to turn off hand faucets.

A nurse is contributing to the plan of care for a client who is being admitted to the facility with a suspected diagnosis of pertussis. Which of the following interventions should the nurse include in the plan of care? (Select all that apply.) A. Place the client in a room that has negative air pressure of that at least six exchanges per hour. B. Wear a mask when providing care within 3 ft of the client. C. Place a surgical mask on the client if transportation to another department is unavoidable. D. Use sterile gloves when handling soiled linens. E. Wear a gown when performing care that might result in contamination from secretions.

B. Wear a mask when providing care within 3 ft of the client. C. Place a surgical mask on the client if transportation to another department is unavoidable. E. Wear a gown when performing care that might result in contamination from secretions.

A nurse is caring for a client who fell at a nursing home. The client is oriented to person, place, and time and can follow directions. Which of the following actions should the nurse take to decrease the risk of another fall? (Select all that apply.) A. Place a belt restraint on the client when he is sitting on the bedside commode. B. Keep the bed in its lowest position with all 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. Make sure that the client's call light is within reach. D. Provide the client with nonskid footwear. E. Complete a fall-risk assessment.

A nurse observes smoke coming from under the door of the staff's lounge. Which of the following actions is the nurses's priority. A. Extinguish the fire. B. Activate the fire alarm. C. Move clients who are nearby. D. Close all open doors on the unit.

C. Move clients who are nearby.

When entering a client's room to change a surgical dressing, a nurse notes that the client is coughing and sneezing. Which of the following actions should the nurse take when preparing the sterile field? A. Keep the sterile field at least 6 ft away from the client's bedside. B. Instruct the client to refrain from coughing and sneezing during the dressing change. C. Place a mask on the client to limit the spread of micro-organisms into the surgical wound. D. Keep a box of facial tissues nearby for the client to use during the dressing change.

C. Place a mask on the client to limit the spread of micro-organisms into the surgical wound.

A nurse is caring for a client who has been sitting in a chair for 1 hr. Which of the following complications is the greatest risk to a client? A. Decreased subcutaneous fat B. Muscle atrophy C. Pressure ulcer D. Fecal impaction

C. Pressure ulcer

A nurse is wearing sterile gloves in peparation for performing a sterile procedure. Which of the following objects can the nurse touch without breaching sterile technique? (Select all that apply.) A. A bottle containing a sterile solution B. The edge of the sterile drape at the base of the field C. The inner wrapping of an item on the sterile field D. An irrigation syringe on the sterile field E. One gloved hand with the other gloved hand

C. The inner wrapping of an item on the sterile field D. An irrigation syringe on the sterile field E. One gloved hand with the other gloved hand

A nurse educator is conducting a parenting class for new parents of infants. Which of the following statements made by a participant indicates understanding of the instructions? A. "I will set my water heater at 130° F." B. "Once my baby can sit up, he should be sage in the bathtub." C. "I will place my baby on his stomach to sleep." D. "Once my infant starts to push up, I will remove the mobile from over the crib."

D. "Once my infant starts to push up, I will remove the mobile from over the crib."

A charge nurse is assigning rooms for the clients to be admitted to the unit. To prevent falls, which of the following clients should the nurse assign to the room closest to the nurses' station? A. A middle adult who is postoperative following a laparoscopic cholecystectomy. B. A middle adult who requires telemetry for a possible myocardial infarction. C. A young adult who is postoperative following an open reduction internal fixation of the ankle. D. An older adult who is postoperative following a below-the-knee amputation.

D. An older adult who is postoperative following a below-the-knee amputation.

A home health nurse is discussing the dangers of carbon monoxide poisoning with a client. Which of the following information should the nurse include in her counseling? A. Carbon monoxide has a distinct odor. B. Water heaters should be inspected every 5 years. C. The lungs are damaged form carbon monoxide inhalation. D. Carbon monoxide binds with hemoglobin in the body.

D. Carbon monoxide binds with hemoglobin in the body.

A nurse is caring for a client who presents with linear clusters of fluid-containing vesicles with some crustings. The nurse should identify the client has manifestations of which of the following conditions? A. Allergic reaction B. Ringworm C. Systemic lupus erythematosus D. Herpes zoster

D. Herpes zoster

A nurse is caring for a client who reports a severe sore throat, pain when swallowing, and swollen lymph nodes. The client is experiencing which of the following stages of infection? A. Prodromal B. Incubation C. Convalescence D. Illness

D. Illness

A nurse has removed a sterile pack from its outside cover and placed it on a clean work surface in preparation for an invasive procedure. Which of the following flaps should the nurse unfold first? A. The flap closest to the body B. The right side flap C. The left side flap D. The flap farthest from the body

D. The flap farthest from the body