Fundamentals A

A nurse is reinforcing teaching with a client who is receiving PCA. Which of the following statements by the client indicates an understanding of the teaching?

"I will not allow anyone to press the PCA button for me"

A nurse is contributing to the plan of care for a client who has a positive throat culture for streptococci. Which of the following interventions should the nurse recommend to be included in the plan of care?

Ensure that the client wears a surgical mask during transportation throughout the facility

A charge nurse smells smoke, enters the visitor restroom, and sees flames in the trash can. What is the sequence of actions that the nurse should take?

Evacuate clients from the area Pull the lever on the fire alarm box Close the fire doors on the unit Use a fire extinguisher to put out the fire

A nurse is reinforcing teaching with a client who has hearing loss about how to modify his home environment. Which of the following is a priority modification that the nurse should include?

Flashing smoke alarm

A nurse is caring for a client who has a Clostridium difficile infection. Which of the following solutions should the nurse use to perform hand hygiene while caring for this client?

Mild soap

A nurse is speaking with a client who has type 2 diabetes mellitus and a prescription for insulin. The client verbalizes anger about having to take insulin. Which of the following responses should the nurse make?

"I see that you are angry. Let's sit down and talk"

A nurse is reinforcing teaching about the use of crutches with a client who has a fractured right tibia and fibula. Which of the following statements by the client indicates an understanding of the teaching?

"I will be sure to keep the crutch tips dry"

A nurse is collecting data from a client who is menopausal. Which of the following statements indicates the nurse should screen the client for depression?

"My family doesn't need me anymore. I've failed them in so many ways"

A client who had a recent below-the-knee amputation says, "I don't know how I can continue to live my life without my leg." Which of the following responses should the nurse make?

"Tell me what concerns you have about your future"

A nurse is caring for a client who has metastatic cancer and practice catholicism. The client asks the nurse to discuss the afterlife with her. Which of the following statements by the nurse assists in meeting the client's spiritual needs?

"Tell me what the afterlife means to you"

A nurse is reinforcing teaching about hospice care measures with the family of a client who is dying. Which of the following statements by a member of the client's family indicate an understanding of the teaching?

"We will keep her room cool to help her breathe better"

A nurse is caring for a client who has recently undergone a total bilateral mastectomy. Which of the following statements by the client requires immediate action by the nurse?

"When I look at myself in the mirror, I don't know if I can go on"

A nurse is reinforcing teaching with a client about the prevention of stress injuries. Which of the following instructions should the nurse include?

"When lifting a heavy object, keep it close to your body"

A nurse is reinforcing dietary teaching with a client who has chronic kidney disease and requires a low potassium diet. Which of the following food choices by the client demonstrates an understanding of the teaching?

1 cup of applesauce

A nurse is calculating the intake and output for a client over the last 8 hr. The client is receiving a continuous IV infusion at 150 ml/hr and had 4 oz of juice and 0.5 L of water. How many ml of fluid should the nurse document as the client's intake for the last 8 hr?

1,820 mL

A nurse is reinforcing teaching with a group of clients about carbon monoxide poisoning. Which of the following information should the nurse include in the teaching?

Headache is a manifestation of carbon monoxide poisoning

A nurse is caring for a client who is refusing medical treatment. Which of the following actions should the nurse take?

Document the client's refusal of the treatment

A nurse is delegated various client care tasks to the assistive personnel (AP) on the care team. Which of the following actions by the AP should the nurse identify as correct?

Donning a mask to measure the vital signs of a client who has pertussis

A nurse is palpating the pulse located on the top of a client's foot. Which of the following pulses should the nurse document that she is palpating?

Dorsalis pedis

A nurse is reviewing the vital signs of four clients. Which of the following findings requires further data collection by the nurse?

A client who has a pulse of 110/min

A nurse is providing wound care for a group of clients. Which of the following wounds should the nurse identify as healing by secondary intentions?

A stage 3 pressure ulcer on the coccyx

A nurse is caring for a client who has an indwelling urinary catheter. Which of the following actions should the nurse take to prevent urinary tract infections?

Drain urine from the tubing before ambulation

A nurse is assisting with the plan of care for a client who has a bacterial infection and a persistent oral temperature of 38.9 C (109 F). Which of the following interventions should the nurse include in the plan of care to treat the fever?

Administer acetaminophen

A nurse is planning to perform wound irrigation for a client who has a large abdominal wound. Which of the following actions should the nurse plan to take?

Administer an analgesic 30 mins before starting the procedure

A nurse is caring for a female client who has urinary incontinence. Which of the following actions should the nurse take?

Apply a moisture skin barrier to the client's perineal area

A nurse is caring for a client who is alert and in a long term care facility. Which of the following should the nurse take to protect the client's privacy?

Ask the client before discussing his condition when family is present

A nurse is assisting with the plan of care for a client who has aphasia following a stroke. Which of the following interventions should the nurse use to assist the client with communication?

Ask the client close-ended questions

A nurse is assisting with the admission of a client who has active tuberculosis. Which of the following actions should the nurse plan to take?

Assign the client to a negative pressure airflow room

A nurse is assisting with the plan of care for four clients. Which of the following tasks should the nurse assign to an assistive personnel (AP)

Assist a client to get out of bed after a breathing treatment

A nurse is using Maslow's hierarchy of needs in assisting with discharge planning for a client. Which of the following activities should the nurse recommend as the priority for this client?

Attend an exercise program

A nurse is explaining ethics and values to a newly licensed nurse. The nurse should explain that allowing a client to make a decision about a treatment is an example of which of the following ethical principles?

Autonomy

A nurse is reviewing the medical record of a client who has heart failure. The nurse should identify which of the following laboratory results as an indication that the client has fluid volume excess?

BUN 8mg/dl

A nurse is caring for a client who has a prescription for a potassium supplement. The client tells the nurse that the pill is too large to swallow and refuses to take it. The nurse offers to break the pill into two smaller pieces. The nurse is demonstrating which of the following ethical principles?

Beneficence

A nurse is caring for a client who is disoriented and at risk for falls. Which of the following actions should the nurse plan to take? (select all that apply)

Ensure that the client is wearing non skid slippers Place the client in a room near the nurses' station Reinforce teaching about how to use the call bell

A nurse is preparing to administer an enteral feeding to a client who has an NG tube in place. Which of the following methods should the nurse use to verify correct placement of the NG tube?

Check the pH of the gastric aspirate

A nurse is assisting with a presentation to a group of older adults at a community center about hypothermia and hyperthermia. Which of the following information should the nurse include about age-related changes?

Circulation becomes less efficient with age

A nurse is preparing to remove a client's peripheral IV catheter. After performing hand hygiene and applying clean gloves, which of the following actions should the nurse take first?

Clamp the infusion tubing

A nurse is contributing to the plan of care for a client who has a prescription for elastic bandages to the lower extremities. Which of the following actions should the nurse recommend for the plan of care?

Compare the client's pedal pulses bilaterally every 4 hr

A nurse is preparing to administer a topical medication to a client. Which of the following actions should the nurse take?

Compare the label of the medication container with the medication administration three times

A nurse is assisting with the admission of a client who has brought her medication to the facility. Which of the following actions should the nurse take?

Compare the medications the provider has prescribed with the client's medications from home

A nurse is caring for a client who is receiving continuous NG tube feeding. The nurse listens to the client's bowel sounds. Which of the following actions should the nurse take?

Decrease the rate of the feeding

A nurse is caring for a client who is postoperative and is experiencing nausea and vomiting. The nurse should identify which of the following findings as indications that the client has fluid volume deficit? (select all that apply)

Decreased skin turgor Orthostatic hypotension Flat neck veins

A nurse is reinforcing teaching with a client about using guided imagery. Which of the following actions should the nurse take?

Direct the client to visualize tension leaving the body

A nurse is caring for a client who has an NG tube and is receiving continuous enteral feeding. Which of the following actions should the nurse take?

Hold the feeding for two consecutive gastric residuals greater than 250 ml

A nurse is repositioning a client who has quadriplegia and is in a supine position. Which of the following should the nurse take to prevent client musculoskeletal injury?

Internally rotate the client's hips by using a trochanter roll

A client who has advanced cancer tells the nurse that he has a difficult time talking to anyone about the illness. Which of the following actions should the nurse take to encourage therapeutic communication?

Let the client know that he is available and willing to listen

A nurse is preparing to administer oxygen to a client who has heart failure and is having severe difficulty breathing. Which of the following oxygen equipment should the nurse select to provide the highest concentration of oxygen to the client?

Non Rebreather mask

A nurse is contributing to the plan of care for a client who has a new prescription for a wrist restraint. Which of the following actions should the nurse include in the plan?

Pad bony prominences on the wrist

A nurse in a long term care facility is contributing to the plan of care for a client who is at risk for pressure ulcers. Which of the following recommendations should the nurse include in the plan?

Perform a thorough skin inspection each day

A nurse is moving a client ip in bed with the assistance of a second nurse. Which of the following actions should the nurse take?

Place feet apart with the foot nearest the head of the client's bed in front of the other foot

A nurse is reinforcing teaching with a client who has a prescription for a transcutaneous electrical nerve stimulation (TENS) unit. Which of the following information should the nurse include in the teaching?

Place the electrodes near the pain site

A nurse is collecting data from a client who has an NG tube set to low intermittent suction. Which of the following findings indicates hypomagnesemia?

Positive chvostek's sign

A nurse is reinforcing teaching with a client about smoking cessation. Which of the following should the nurse identify as the first stage of health behavior change?

Precontemplation

A nurse is reinforcing preoperative teaching with a client who does not speak the same language as the nurse. Which of the following actions should the nurse take?

Provide handouts written in the client's primary language

A charge nurse is reinforcing teaching with an assistive personnel (AP) about performing pulse oximetry. Which of the following should the nurse include in the teaching?

Remove polish from the client's fingernail before applying the oximetry probe

A nurse is reinforcing teaching with an older adult client about oral hygiene. Which of the following instructions should the nurse include in the teaching?

Replace her toothbrush following an illness

A nurse writes client information on a piece of paper while receiving report. Which of the following actions should the nurse take to dispose of the paper?

Shred the paper in a secure container

A nurse is reinforcing teaching with an older adult client who reports an inability to sleep. Which of the following should the nurse include when teaching the client about aging and sleep?

Sleep patterns change with age

A nurse is collecting data from an older adult client. Which of the following findings should the nurse report to the provider?

The client reports urinary incontinence

A nurse is reinforcing teaching about health promotion with a group of young adult clients. Which of the following information should the nurse include?

Young adults should receive a dental assessment every 6 months