FUndamentals A

a nurse is caring for a client who has dementia. which of the following interventions should the nurse take to minimize the risk for injury to the client?

Use a bed exit alarm system. The nurse should identify that a client who has dementia requires assistance when exiting their bed and might be unable to remember to ask for help. The client's condition places them at a risk for falling; therefore, a bed alarm system can alert staff members that the client is trying to get out of bed and requires assistance.

a nurse is auscultating the anterior chest of a client newly admitted to a medical-surgical unit. listen to the audio clip of what the nurse auscultates through his stethoscope and identify the type of breath he hears

Normal breath sounds These are normal bronchovesicular breath sounds, characteristically of moderate intensity and sounding like blowing as air moves through the larger airways on inspiration and expiration.

a nurse is planning to insert a peripheral IV catheter for an older adult client. which of the following actions should the nurse plan to take?

Place the client's arm in a dependent position. The nurse should place the client's arm in a dependent position because the veins will dilate due to gravity.

a nurse is reviewing evidence-based practice principles about administration of oxygen therapy with a newly licensed nurse. which of the following actions should the nurse include?

Regulate oxygen via nasal cannula at a flow rate of no more than 6 L/min. Evidence-based practice supports a flow rate of 1 to 6 L/min via nasal cannula. Rates above 6 L/min have a drying effect and force clients to swallow air excessively without increasing their fraction of inspired oxygen (FiO2).

a nurse is assessing a client who reports increased pain following physical therapy. which of the following questions should the nurse ask when assessing the quality of the client's pain?

"Is your pain sharp or dull?" Asking the client whether the pain is sharp, dull, crushing, throbbing, aching, burning, electric-like, or shooting helps determine the quality of the pain. "Is your pain constant or intermittent?"Asking the client whether the pain is constant or intermittent determines the onset, duration, and pattern of the pain. "What would you rate your pain on a scale of 0 to 10?"Asking the client to rate the pain using the pain scale determines the intensity of the pain. "Does the pain radiate?"Asking the client whether the pain radiates determines the pain's location.

a nurse is preparing to administer enoxaparin subcutaneously to a client. which of the following actions should the nurse take?

Administer the medication with the needle at a 45° angle. The nurse should insert the needle at a 45° to 90° angle for a subcutaneous injection.

a nurse is admitting a client who is having an exacerbation of heart failure. in planning this client's care, when should the nurse initiate discharge planning?

During the admission process Discharge planning should begin as soon as the client is undergoing the admission process. The nurse should begin to assess the client's needs and plan for care both during and after the client's time in the facility.

a nurse is caring for a child who has a prescription for a blood transfusion. the child's parents have refused the treatment due to their religious beliefs. which of the following actions should the nurse take?

Examine personal values about the issue. Nurses should examine their own personal values about the issue in question in order to provide care that is without bias.

a nurse is providing discharge instructions to a client who will be using a walker. which of the following client statements indicates an understanding of the teaching?

"I will hire someone to trim the tree that hangs low over the stairs of my front porch." Clearing stairs of any object that could cause the client to trip or require them to bend over while walking will decrease the risk for falls.

a nurse is performing a skin assessment for a client who expresses concern about skin cancer. which of the following findings should the nurse identify as a potential indication of a skin malignancy?

A mole with an asymmetrical appearance An uneven or asymmetrical shape is a potential indication of a skin malignancy. This is manifested when part of a lesion or mole looks different from the other part.

a nurse is assessing a client's readiness to learn about insulin self-administration. which of the following statements should the nurse identify as an indication that the client is ready to learn?

"I can concentrate best in the morning." The client's statement indicates a readiness to learn because he is verbalizing the best time for him to learn.

A nurse is preparing to administer 0.9% sodium chloride 750 mL IV to infuse over 7 hr. The nurse should set the infusion pump to deliver how many mL/hr? (round to nearest whole number. Use a leading zero if it applies. Do not use a trailing zero)

107 mL/hr

a nurse is planning care for a client who has had a stroke, resulting in aphasia and dysphagia. which of the following tasks should the nurse assign to an assistive personnel? Select all that apply?

Assist the client with a partial bed bath is correct. Assisting a client with a bed bath poses minimal risk to the client and is within the AP's range of function. Measure the client's BP after the nurse administers an antihypertensive medication is correct. Measuring a client's BP poses minimal risk to the client and is within the AP's range of function. Use a communication board to ask what the client wants for lunch is correct. Using a communication board poses minimal risk to the client and is within the AP's range of function.

a nurse is caring for a client who is expressing anger about his diagnosis of colorectal cancer. which of the following actions should the nurse take?

Reassure the client that this is an expected response to grief. During the anger stage of the client's psychosocial adaptation to illness, the nurse should support the client and explain that this is an expected reaction to a cancer diagnosis.

A nurse is talking with an older adult client who is contemplating retirement. The client states, "I keep thinking about how much I enjoy my job. I'm not sure I want to retire." Which of the following responses should the nurse make?

"Let's talk about how the change in your job status will affect you." This response is therapeutic because the nurse is encouraging the client to verbalize feelings about the life transition of retirement. "You would have so much more time to spend with your family."This response is nontherapeutic because the nurse is minimizing the client's feelings and making assumptions about the client's relationships. "You should consider getting a part-time job or doing volunteer work."This response is nontherapeutic because the nurse is minimizing the client's feelings and offering personal advice. "Why wouldn't you want to retire and relax?"This response is nontherapeutic because the nurse is asking a "why" question, which can provoke a defensive response from the client.

a nurse is caring for a client for asks about the purpose of advance directives. which of the following statements should the nurse make?

"They indicate the form of treatment a client is willing to accept in the event of a serious illness." Advance directives include a living will, which permits clients to direct the treatment they will receive in the event of a medical emergency or serious illness.

A nurse is educating a client who has a terminal illness about declining resuscitation in a living will. The client asks, "What would happen if I arrived at the emergency department and I had difficulty breathing?" Which of the following responses should the nurse make?

"We would give you oxygen through a tube in your nose." Oxygen can provide comfort and is not considered a resuscitative measure when the nurse delivers it via nasal cannula.

A nurse in a long-term care facility is caring for a client who dies during the nurse's shift. Identify the sequence in which the nurse should perform the following steps.

1) obtain the pronouncement of death from the provider 2)remove the tubes and indwelling lines 3) wash the client's body 4) ask the client's family if they would like to view the body 5) place a name tag on the body The first step is to obtain the death pronouncement from the provider. Next, the nurse should remove tubes and indwelling lines prior to cleansing the client's body. After cleansing, the nurse should ask the family members if they wish to view the body. Finally, the nurse should place a name tag on the body before transfer.

a nurse is caring for a client who has a sodium level of 125 mEq/L. which of the following findings should the nurse expect?

Abdominal cramping This client has hyponatremia, which is a low sodium level. Manifestations include abdominal cramping, weakness, confusion, lethargy, headache, and nausea.

a nurse is providing discharge teaching to a client about self-administering heparin. which of the following instructions should the nurse include in the teaching?

Administer the medication into the abdomen. The nurse should instruct the client to administer the medication into the abdomen at least 5.08 cm (2 in) from the umbilicus. The client should pinch or spread the skin at the injection site to administer the medication into the subcutaneous tissue.

a nurse is preparing an education program for staff about advocacy. which of the following information should the nurse include?

Advocacy ensures clients' safety, health, and rights. Advocacy is a key component of professional nurses' code of ethics. As a client advocate, the nurse ensures clients' safety, health, and rights, including the right to privacy, confidentiality, and refusal of care.

a nurse is caring for a client who has a respiratory infection. Which of the following techniques should the nurse use when performing nasotracheal suctioning for the client?

Apply intermittent suction when withdrawing the catheter. The nurse should apply intermittent suction during the withdrawal of the catheter to prevent injury to the mucosa. However, suctioning continuously for more than 10 seconds can cause cardiopulmonary compromise.

a nurse is assessing a client who has required bed rest for the past month. which of the following findings should the nurse identify as an indication that the client has developed thrombophlebitis?

Calf swelling Swelling, redness, and tenderness in a calf muscle are manifestations of thrombophlebitis, a common complication of immobility.

a nurse is responding to a call light and finds a client lying on the bathroom floor. which of the following actions should the nurse take first?

Check the client for injuries. The first action the nurse should take when using the nursing process is to assess the client for injuries.

a nurse is administering 1 L of 0.9% NaCl to a client who is postoperative and has fluid volume deficit. which of the following changes should the nurse identify as an indication that the treatment was successful?

Decrease in heart rate Fluid volume deficit causes tachycardia. With correction of the imbalance, the heart rate should return to the expected range.

a nurse is caring for a client who requires an NG tube for stomach decompression. which of the following actions should the nurse take when inserting the NG tube?

Have the client take sips of water to promote insertion of the NG tube into the esophagus. Taking sips of water as the NG tube passes through the oropharynx will close the epiglottis over the trachea and prevent the tube from passing into the trachea.

a nurse is initiating a protective environment for a client who has had an allogeneic stem cell transplant. which of the following precautions should the nurse plan for this client?

Make sure the client wears a mask when outside her room if there is construction in the area. An allogeneic stem cell transplant compromises the client's immune system, greatly increasing the risk for infection. The client will need protection from breathing in any pathogens in the environment.

A nurse on a medical-surgical unit is caring for a client who has a new prescription for wrist restraints. Which of the following actions should the nurse take?

Pad the client's wrist before applying the restraints. The use of restraints without padding can abrade the client's skin, resulting in client injury. The nurse should evaluate the client's circulation, range of motion, vital signs, and overall status every 15 min after initial application of restraints. The nurse should remove the restraints at least every 2 hr to reposition the client and assess needs for hygiene and toileting. The nurse should secure the restraint ties to a part of the bed frame that moves with the client to reduce the risk of injury.

a nurse is administering an otic medication to an older adult client. which of the following actions should the nurse take to ensure that the medication reaches the inner ear?

Press gently on the tragus of the client's ear. Pressing gently on the tragus of the ear will help the medication get into the inner ear.

a nurse is preparing a change-of-shift report. which of the following tools or documents should the nurse use to communicate continuity of care?

Situation, background, assessment, and recommendation (SBAR) SBAR is a communication tool nurses use to relate a client's status during a change-of-shift report.

a nurse is performing a home safety assessment for a client who is receiving supplemental oxygen. which of the following observations should the nurse identify as proper safety protocol?

The client uses nonacetone nail polish remover. The client should use nonflammable materials, such as nonacetone nail polish remover, while using supplemental oxygen.

a nurse is caring for a client who has a terminal illness and is approaching death. the client is short of breath and has noisy respirations from secretions in their airway. which of the following actions should the nurse take?

Turn the client every 2 hr. The nurse should turn the client at least once every 2 hr to break up the secretions in the client's lungs and prevent noisy respirations.

a nurse is planning strategies to manage time effectively for client care. which of the following strategies should the nurse implement?

Use the planning step of the nursing process to prioritize client care delivery. Setting up a list of goals and tasks to perform for clients can help the nurse set care priorities and plan tasks accordingly. The priority to-do list is an efficient tool for optimal time management.

a nurse in a provider's office is assessing the deep tendon reflexes of a client. which of the following images should the nurse identify as indicating the correct technique for eliciting the client's patellar reflex?

patella is the knee so..

a nurse is assessing an older adult client's risk for falls. which of the following assessments should the nurse use to identify the client's safety needs? (select all that apply)

pupil clarity, visual fields, visual acuity

a home health nurse is performing a follow-up visit for a client who has a gastrostomy tube through which they receive intermittent feedings and medications. the client has recently developed diarrhea. which of the following findings should the nurse identify as a possible cause of the diarrhea?

the client's caregiver washes out the feeding bag with warm water once every 24 hr Feeding bags should be washed out after each feeding and replaced with a new feeding bag every 24 hr to prevent bacterial contamination. The nurse should reinforce this information with the client's caregiver to avoid future contamination. Cold formula can cause gastric cramping; therefore, room temperature formula is appropriate and is likely not the cause of the client's diarrhea. Diarrhea is more likely to develop with rapid instillation of enteral formula. It is correct to flush tubing with water before and after administering medications to prevent clogging of the tube.

a nurse is teaching a client and his family how to care for the client's tracheostomy at home. which of the following instructions should the nurse include in the teaching?

use tracheostomy covers when outdoors Tracheostomy covers protect the client's airway from cold air, dust, and other airborne particles.