Fundamentals - Exam 1

A client with an upper respiratory infection (common cold) tells the nurse, "I am so angry because the nurse practitioner would not give me any antibiotics." What would be the most appropriate response by the nurse?

"Antibiotics have no effect on viruses."

A hospital utilizes the SOAP method of charting. Within this model, which of the nurse's statements would appear at the beginning of a charting entry?

"Client is reporting that her abdominal pain is rated at 8/10."

The home health nurse is providing care to a number of clients. Which client assessed by the nurse will require hospitalization related to complications associated with the feet?

The client with peripheral vascular disease Foot problems, particularly common in people with diabetes mellitus and peripheral vascular disease, often require hospitalization. Clients who have osteoporosis, asthma, and diabetes insipidus do not have an increased incidence of foot problems as a result of their disease.

A nurse is helping an older woman undress and notices the woman's knee-high hose have left deep indentations. The woman has diabetes. Does this pose a risk to the client?

Yes, these can obstruct lower extremity circulation.

A nurse working in long-term care facility is assessing residents at risk for the development of a pressure injury. Which resident would be most at risk?

a client 68 years of age who is bedfast related to severe head trauma

Which client's vital signs will the nurse assess every four hours?

a client hospitalized with hypertension

The nurse would recognize which client as being particularly susceptible to impaired wound healing?

an obese woman with a history of type 1 diabetes

What are the recommended cleansing agents for hand hygiene in any setting when the risk of infection is high?

antimicrobial products

Which statement by a client would indicate that a nurse had successfully implemented an educational strategy to prevent injury in the home?

"I have removed all throw rugs on the floor."

The nurse is assisting an older adult client with dementia in getting dressed after morning care. Which statement would be most beneficial to the client?

"Put your arm in this sleeve."

A nurse is conducting a health history for a client with a skin problem. What question or statement would be most useful in eliciting information about personal hygiene?

"Tell me about what you do to take care of your skin."

The nurse is admitting a client who underwent a hip replacement several weeks ago. The client now has a methicillin-resistant Staphylococcus aureus (MRSA) infection in the nonhealing hip wound. What actions would the nurse implement? Select all that apply.

- Assess and document the client's wound. - Administer intravenous vancomycin. - Assign the client to a private room.

To ensure accurate charting, which actions should the nurse perform? Select all that apply.

- Checks to make sure that the nurse has the correct chart prior to making an entry - Documents interventions as close as possible to the time of execution - Places a label with the client's name and identification number on each page of the client's chart

The nurse is providing care to a postoperative client who has a Jackson-Pratt (JP) drain. The nurse notes that the JP drain is expanded and full of sanguineous fluid. Place in order the steps the nurse will now perform. Use all options.

- Don clean gloves. - Empty the JP's contents into a graduated collection container. - Compress the chamber and replace the JP cap. - Note the amount of output, as well as its color. - Remove gloves and sanitize or wash hands.

The nurse is providing care to an older adult client. Which intervention(s) will the nurse perform to protect the client's skin? Select all that apply.

- apply moisturizing lotion to feet and hands daily - minimize the use of any tape on the skin - wash the perineal area every day - offer fluids every hour while the client is awake

A client who has an immobilizer on the arm reports shortness of breath following ambulation to the bathroom. The nurse notes the client's pulse increased from 82 to 124 beats/min, respirations increased from 16 to 24 breaths/min, and blood pressure is 90/50 mmHg. The nurse makes the nursing diagnosis of Activity Intolerance. What are the client's defining characteristics for this diagnosis? Select all that apply.

- client reports of shortness of breath - increase in pulse rate - increase in respiratory rate - decrease in blood pressure

The nursing is preparing to provide hygiene to a middle-aged male client who practices Christianity. The client told the nurse that he had his bath yesterday and does not need a bath today. What factors may be the reasons the client declined the bath? Select all that apply.

- culture - health status - personal preferences

The following are prescriptions on a client's chart. Which prescriptions would the nurse question because they are written incorrectly? Select all that apply.

- heparin 5000U subcutaneously every day - metoprolol 25 mg po daily, hold if BP <100 mm Hg - vancomycin 750 mg IV qod

The nurse triaged a number of clients in the emergency department. Which clients would the nurse identify as Risk for Infection? Select all that apply.

- the client who has AIDS and is taking antiretroviral medications - the client who reports abdominal pain for 1 day and exhibits an elevated white blood cell count - the client who has breast cancer, is receiving chemotherapy, and has a low white blood cell (WBC) count - the older adult client who is cachectic in appearance

The nurse is caring for a client following major surgery. Which intervention helps to prevent orthostatic hypotension in the postsurgical client?

Administer intravenous fluids per the health care provider's prescription. Circulating fluid volume is often decreased following surgical procedures. As such, intravenous fluids are administered to restore fluid loss and prevent orthostatic hypotension. Assisting the client out of bed upon standing is important for the client's safety but does not prevent orthostatic hypotension. Administering prophylactic antibiotics helps to prevent infections following surgical procedures. The nurse, not the family, should assist the client during ambulation.

A nurse is explaining the need for bathing to an elderly client who has been avoiding a daily bath. Which benefit of bathing should the nurse explain to the client?

Bathing reduces the possibility of infection.

A client presents to the emergency department with profuse bleeding from a crushing injury while at work. Which set of vital signs does the nurse anticipate finding in such this client?

Blood pressure 80/50 mm Hg, heart rate 120 beats/min, respiratory rate 24 breaths/min

A nurse has completed morning care for a client. There is no visible soiling on the nurse's hands. What type of technique is recommended for hand hygiene?

Clean hands with an alcohol-based handrub.

A postsurgical client and family have differing opinions about the level of pain that the client is experiencing. Which is the best way to educate the client and family about pain and pain relief?

Discuss with the family that the client is the best person to describe its level.

A client 80 years of age experienced dysphagia (impaired swallowing) in the weeks following a recent stroke, but his care team wishes to now begin introducing minced and pureed food. How should the nurse best position the client?

Fowler's

The infection control nurse will be educating the clinical staff about a new infection control initiative that is being introduced at the health care facility. The initiative will further emphasize the need for hand hygiene. What information is important for the infection control nurse to include when educating the clinical staff?

Full compliance with hand hygiene is difficult to achieve.

A nursing home recently has had a significant number of nosocomial infections. Which measure might be instituted to decrease this trend?

Have written, infection-prevention practices for all employees

Which priority action should be implemented by the charge nurse when observing a new graduate nurse perform the procedure displayed in the image?

Inform the new nurse to wear gloves when obtaining specimens that contains bodily fluids

A client comes to the emergency department with major burns over 40% of his body. Although all of the following are true, which one would provide the rationale for a nursing diagnosis of Risk for Infection?

Intact skin and mucous membranes protect against microbial invasion.

A nurse asks a client to rate the pain on a scale of 0 to 10, with 0 being no pain and 10 being the worst pain. Which information will the nurse gather next to establish the client's baseline pain experience?

Location

A nurse makes a medication error and fills out an incident report. What will the nurse do with the incident report once it is filled out?

Maintain it according to agency policy.

A postoperative client who has been receiving morphine for pain management is exhibiting a depressed respiratory rate and is not responsive to stimuli. Which drug has the potential to reverse the respiratory-depressant effect of an opioid?

Naloxone

A nurse is admitting a client to a geriatric medicine unit. Which nursing action would the nurse perform to reduce the client's risk for a fall?

Orient the client to the room and environment upon admission.

A home health nurse is visiting an older adult client after surgical knee replacement. What assessment parameters are most essential to evaluate and document?

Presence of abnormalities that would impede healing

Upon review of the client's orders, the nurse notes that the client was recently started on an anticoagulant agent. What is an appropriate consideration when assisting the client with morning hygiene?

Provide the client with an electric shaver.

The nurse is preparing to perform perineal care on an uncircumcised adult male client who was incontinent of stool. The client's entire perineal area is heavily soiled. Which technique for cleaning the penis is correct?

Retract the foreskin while washing the penis, and then immediately pull the foreskin back into place.

What organ is the primary site of heat loss in the body?

Skin

A nurse is completing an intake assessment. The nurse notes that an older adult male client appears to have bruises in varying stages of healing. Which action by the nurse indicates an understanding of her responsibilities?

The nurse should question the client about the source of the bruises.

The nurse notes a difference in systolic blood pressure readings between the client's arms. How will the nurse approach subsequent readings based upon this difference in blood pressures?

The nurse will use the arm with the highest reading.

A nurse is caring for a client with a wound on the lower extremity. What findings would the nurse observe that would indicate an infection?

The wound base appears swollen and red, with yellow purulent drainage, and the client's oral temperature is 99°F (37.2° C).

Who is the authority on the presence and extent of pain experienced by a client?

the client

An older adult resident of a long-term care facility has recurring problems with dry skin. Which strategy should the nursing staff utilize in order to help meet the resident's hygiene needs while preventing skin dryness?

Use a nonsoap cleaning agent.

The nurse has just completed programming of a patient-controlled analgesia (PCA) pump using prescribed parameters. Which action should the nurse take next?

Verify the settings with another nurse.

An obese client has developed peripheral edema as a consequence of heart failure, making it very difficult for the student nurse to accurately palpate the client's peripheral pulses. How should the nurse proceed with this assessment?

auscultate the client's apical pulse

What ensures continuity of care?

communication

Upon review of a postoperative client's medication list, the nurse recognizes that which medication will delay the healing of the operative wound?

corticosteroids Clients who are taking corticosteroids or require postoperative radiation therapy are at high risk for delayed healing and wound complications. Corticosteroids decrease the inflammatory process, which may delay healing. Antihypertensive drugs, potassium supplements, and laxatives do not delay wound healing.

Which condition will lead to an increase in cardiac output?

exercise

When the nurse cleanses the client's leg during a bed bath, it will allow for:

increased circulation.

Upon assessing a client who is hemorrhaging, the nurse is most likely to assess which compensatory change in vital signs?

increased pulse rate

The nurse managers of a home health care office wish to maximize nurses' freedom to characterize and record client conditions and situations in the nurses' own terms. Which documentation format is most likely to promote this goal?

narrative notes

The nurse places a client experiencing labored breathing in an upright position. The nurse notes that the client is able to breathe more easily in this upright position and documents this condition on the chart as:

orthopnea

A nurse is filling out an incident report after an older adult client fell while attempting to transfer from her bed to a commode. Which health problem should the nurse consider when client falls occur?

orthostatic hypotension

While receiving a report, the nurse learns that a client has paraplegia. The nurse will plan care for this client based upon the understanding that the client has:

paralysis of the legs.

The nurse assists the client to the bathroom sink to perform morning care. The nurse observes the client wash his face, arms, abdomen, and legs. The nurse washes the client's back and rectal area and applies soap to the back. The client brushes his teeth and ambulates to a chair in his room with assistance. How will the nurse describe the morning care on the client's chart?

partial care

A nurse is caring for a client with laceration wounds on the knee. The nurse notes that the client is in remodeling phase of wound repair. Which statement describes this phase of wound recovery?

period during which the wound undergoes changes and maturation

Nurse T. has auscultated Mr. Weinstein's apical pulse while a colleague simultaneously palpated his radial pulse. This assessment of Mr. Weinstein's apical-radial pulse indicates that the two values differ significantly, a finding that suggests which health problem?

peripheral vascular disease

A medical-surgical nurse is assisting a wound care nurse with the debridement of a client's coccyx wound. What is the primary goal of this action?

removing dead or infected tissue to promote wound healing

The nurse has started an intravenous catheter in the client's hand. What type of dressing will the nurse use to secure the IV catheter?

transparent film

A nurse is educating a rural community group on how to avoid contracting West Nile virus by using approved insect repellant and wearing proper coverings when outdoors. By what means is the pathogen involved in West Nile virus transmitted?

vectors

A nurse is performing a sterile dressing change. If new sterile items or supplies are needed, how can they be added to the sterile field?

with sterile forceps or hands wearing sterile gloves