Fundamentals Final
what method of assessment should a nurse use first when assessing a patient who reports feeling bloated for several weeks? A. inspection B. ausculation C. percussion D. palpation
A
Which of the following alterations would heal by secondary intention? Select all that apply. A. Stage 3 pressure injury B. Casted bone fracture C. Open burn area D. Sutured surgical incision D. Laceration sealed with adhesive
A E
what action should the nurse plan to take when preparing to administer a cleansing enema to a patient? A. Insert the rectal tube 15.2 cm (6 in). B. Wear sterile gloves to insert the tubing. C. Position the client on his left side. D. Hold the solution bag 91 cm (36 in) above the client's rectum.
C This facilitates the flow of the enema solution into the sigmoid and descending colon.
What medication should you always write the full name out instead of using abbreviations?
magnesium sulfate
What is the most common clinical manifestation of hyperkalemia?
muscle weakness
What value indicates a client is in catabolic state?
negative nitrogen balance
Can UAP's irrigate a clients indwelling urinary catheter?
no
A nurse is caring for a client who is postoperative following a vaginal hysterectomy and asks for a drink. Her postoperative diet prescription reads: clear liquids; advance diet as tolerated. Which of the following responses should the nurse make? A. Lunch trays will be here soon B. Im going to listen to your abdomen C. Ill get you some water to drink D. I would wait a bit, you might feel sick after drinking liquids.
"I am going to listen to your abdomen." a common reason why client's experience nausea and vomiting after a surgery is bc of delayed gastric emptying time or decreased peristalsisdetermine presence of bowel sounds before liquids can be administered
What are the three risk factors for developing osteoprosis?
- family history - ciagrette smoking - inactivity
What two electrolyte imbalances does a positive Chovsteks sign indicate?
- hypocalcemia - hypomagnesmia
What are the correct steps in caring for a client who has deceased
- obtain pronouncement of death - remove tubes - wash body - ask family members if theyd like to view body - place name tag on body
What are the three most common side effects of opiods?
- orthostatic hypertension - bradypnea - nausea
What is the normal range for creatinine?
0.5-1.1 mg/dL
What is the normal range for BUN?
10-20 mg/dL
What is the normal range for sodium?
136-145 mEq/L
What is the BMI of someone with a healthy weight?
18.5 - 24.9
When should you recieve a pneummococal vaccine?
19 years old, or when they have certain chronic conditions
Within what time period before bed should you NOT excercise?
2 hours before bed
What is the normal range for potassium?
3.5-5.0 mEq/L
What is the BMI of an obese person?
30 or over
A nurse in a provider's office is assessing a client who has heart failure. The client has gained weight since her last visit and her ankles are edematous. Which of the following findings by the nurse is another clinical manifestation of fluid volume excess? A. bounding pulse B. hypotension C. poor skin turgor D. sunken eyes
A
A nurse is performing suctioning for a client who has a tracheostomy. Which of the following actions should the nurse take? A. Pull suction back 1 cm if the client starts coughing B. Allow 30 seconds between suctioning passes C. Hyperventilate the client with 50% oxygen for 30 seconds D. Perform a maximum of 4 passes with the suction catheter
A
A nurse is planning to administer pain medication to a client who has pain following abdominal surgery. Which of the following actions should the nurse take first? A. Use the pain scale to find out clients pain level B. Take vital signs C. Tell the patient about the associated adverse effects D. check for allergies
A
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 client's commitment to a long-term goal of weight loss? a. Attempt to increase the clients self motivation b. Keep detailed records of each client's progress c. Test client learning after each teaching session d. Avoid discussing areas that might cause client anxiety
A
A nurse is providing oral care for a client who is unconscious. Which of the following actions should the nurse take? A. Place the client in a lateral position with the head turned to the side before beginning the procedure. B. Use the thumb and index finger to keep the client's mouth open. C. Rinse the client's mouth with an alcohol-based mouth wash following the procedure. D. Cleanse the client's mucous membranes with lemon-glycerin sponges.
A
A nurse is providing teaching to a group of unit nurses about wound healing by secondary intention. Which of the following information should the nurse include in the teaching? A. Remove the sleeve of the gown from the arm without the IV line B. Slow the infusion using the roller clamp C. Disconnect the IV line from the pump D. Bring the IV solution and tubing from the outside to the end side of the sleeve of the gown
A
A nurse is using the I-SBAR communication tool to provide the client's provider with information about the client. The nurse should convey the client's pain status in which portion of the report? a. Assessment b. Background c. Situation d. Recommendation
A
a nurse is caring for a patient who is receiving a blood transfusion. the patient reports flank pain and the nurse notes reddish-borwn urine in the patient's urinary catheter bag. the nurse recognizes these manifestations as what type of transfusion reaction? A. Hemolytic B. Febrile C. Circulatory overload D. Sepsis
A
a nurse is preparing to provide chest physiotherapy for a patient who has left lower lobe atelectasis. what action should the nurse plan to take? A. Place the client in Trendelenburg's position. B. Perform percussions directly over the client's bare skin. C. Use a flattened hand to perform percussions. D. Remind the client that chest percussions can cause mild pain.
A
a nurse on a mental health unit is preparing to terminate the nurse-patient relationship with a patient who no longer requires care. what concepts should the nurse and patient discuss in the termination phase of the relationship? A. Loss B. Guilt C. Trust D. Self-disclosure
A
what action should the nurse take when a patient is performing passive range-of-motion exercises? A. Repeat each joint motion five times during each session. B. Move the joint to the point of considerable resistance. C. Sit approximately 2 feet from the side of the bed closest to the joint being exercised. D. Exercise the smaller joints first.
A
A nurse is preparing to administer an IM injection to a client who is overweight. Which of the following sites should the nurse select for injection? A. The lower, medial quadrant of the buttock near the coccyx B. The side hip between the iliac crest and anterior iliac spine C. The tissue of the posterior upper arm D. The lower, inner thigh 4 finger widths above the patella
B
A nurse is preparing to anchor with tape the catheter tube for a male client who has a newly inserted indwelling urinary catheter. At which of the following locations should the nurse tape the catheter? A. Lateral thigh B. Lower abdomen C. Mid-abdominal region D. Medial thigh
B
A nurse is reinforcing teaching of postoperative deep breathing and coughing exercises with a client who will have emergency surgery for appendicitis. Which of the following statements indicates a lack of readiness to learn by the client? A. The client asks the nurse to repeat the instructions before attempting the exercise B. The client reports severe pain C. The client asks the nurse how often deep breathing should be done after surgery D. The client tells the nurse that this exercise will pr
B
A nurse is teaching a client who is recovering from gallbladder surgery how to use an incentive spirometer. Which of the following information should the nurse include in the teaching? A. Exhale slowly to reach goal volume. B. Hold breath for 5 seconds after goal volume is reached. C. Continue to deep breathe between each cycle. D. Limit repeat pattern of breathing to 5 breaths.
B
Which of the following activities is an example of the nurse promoting primary prevention? a. Teaching clients to perform self-examinations of breast and testicles b. Educating clients about the recommendation immunization schedule for adults c. Teaching clients who have type 1 diabetes mellitus about care of the feet d. Recommending the clients over the age of 50 have fecal occult blood test annually.
B
A nurse is caring for an older adult client who has dysphagia following a cerebrovascular accident. Which of the following actions should the nurse take when assisting the client at mealtime? a. Encourage the client to drink fluids before swallowing food. b. Offer the client tart or sour foods first. c. Tilt the client's head backward when swallowing. d. Turn on the television.
B The client who has impaired pharyngeal swallowing should consume tart and sour foods at the beginning of the meal to stimulate saliva production, which helps with chewing and swallowing.
what action should the nurse include in the plan of care for a patient who has a single-lumen NG tube for gastric decompression? A. Set the suction machine at 120 mm HG. B. Provide oral hygiene frequently. C. Measure the amount of drainage from the NG tube every shift. D. Secure the NG tube to the client's gown. E. Apply petroleum jelly to the client's nares.
B, C, D
A nurse is administering a cleansing enema to a client who is scheduled for a diagnostic procedure. Which of the following actions should the nurse take? A. Lubricate up to 3.2 cm (1.25 in) of the tip of the rectal tube. B. Position the client on his right side. C. Insert the tip of the tubing 8 cm (3.1 in). D. Hold the enema container 61 cm (24 in) above the rectum.
C
A nurse is caring for a child who is postoperative following a tonsillectomy. Which of the following actions should the nurse take? A. Encourage the child to cough frequently to clear congestion from anesthesia B. Place a heating pad at the childs neck for comfort C. Administer analgesics to the child on a routine schedule throughout the day and night D. Provide the child with ice cream when oral intake is initiated.
C
A nurse is measuring a client's vital signs and notices an irregularity in the pulse. Which of the following actions should the nurse take? A. Measure the pulse using a Doppler ultrasound stethescope B. Check the clients pedal pulses C. Count the apical pulse rate for 1 full minute, and described the rhythm in the chart. D. Take the pulse at each peripheral site and count the rate for 30 seconds.
C
A nurse is performing eye irrigation for a client who was exposed to smoke and ash. Which of the following actions should the nurse take? A. Hold the irrigator 1.25 cm (0.5 in) above the eye. B. Direct the irrigation solution upward toward the upper eyelid. C. Exert pressure on the bony prominences when holding the eyelids open. D. Direct the irrigation from the outer canthus to the inner canthus of the eye.
C
A nurse is planning care for an adult client who has fluid volume excess. Which of the following interventions should the nurse plan to include to monitor the client's weight? A. Calibrate the scales weekly. B. Use a different scale each time. C. Weigh the client on arising. D. Weigh the client without clothing.
C
A nurse is preparing to insert an NG tube for a client who has a bowel obstruction. Which of the following actions should the nurse take first? A. Provide the client with a glass of water. B. Assist the client to a sitting position. C. Explain the procedure to the client. D. Measure the length of tubing to be inserted.
C
A nurse is preparing to remove an NG tube for a client who had a partial colectomy. Which of the following actions should the nurse take? A. Maintain suction while removing the NG tube. B. Instill 100 mL of air into the NG tube before removal. C. Pinch the NG tube while removing the tube. D. Instruct the client to breathe in and out during the removal of the NG tube.
C
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? A. Washes each part of her hands with 5 strokes B. Washes from the elbows down to the hands C. Washes with her hands held higher than her elbows D. Uses minimal friction while washing her hands.
C
Which of the following indicates that a urinary catheter needs to be irrigated? A. Urine has an unusual odor B. Urine specific gravity is 1.035 C. Bladder scan shows 525 mL of urine D. urine is positive for ketones
C
what type of enema should the nurse plan to administer rot soften the feces of a patient who has a fecal impaction before digital removal of the mass? A. carminative B. hypertonic C. oil retention D. sodium polystyrene sulfate
C
which instructions should the nurse include in the teaching of four-point crutch gait for a patient with lower extremity weakness? A. "Support the majority of your weight on the axillae." B. "Keep your elbows extended." C. "Bear weight on both of your legs." D. "Move both crutches forward at the same time."
C
A nurse is caring for a client who reports abdominal pain. An assessment by the nurse reveals the client has a temperature of 39.2 heart rate of 105/min, a soft contender abdomen, and menses overdue by 2 days. Which of the following findings should be the nurse's priority? A. Heart Rate 105/min B. Soft, nontender abdomen C. Temperature D. Overdue menses
C Elevated temperature is an emergent physiological need, which requires priority intervention by the nurse. The nurse should consider Maslow's Hierarchy of Needs, which includes five levels of priority. The first level consists of physiological needs; the second level consists of safety and security needs; the third level consists of love and belonging needs; the fourth level consists of personal achievement and self-esteem needs; and the fifth level consists of achieving full potential and the ability to problem solve and cope with life situations. When applying Maslow's Hierarchy of Needs, the nurse should review physiological needs first. The nurse should then address the client's needs by following the remaining four hierarchal levels. However, it is important for the nurse to consider all contributing client factors, as higher levels of the pyramid can compete with those at the lower levels, depending on the situation.
A nurse at a screen 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? a. Fifth intercostal space just medial to the midclavicular line b. Second intercostal space to the left of the sternum c. Fifth intercostal space to the left of the sternum d. Second intercostal space to the right of the sternum
D
A nurse is witnessing a client sign an informed consent form for surgery. which of the following describes what the nurse is affirming by this action? A. The client fully understand the providers explanation of the procedure. B. The client has been informed about the risks and benefits of the procedure. C. The nurse witnessed the providers explanation of the procedure. D. The signature on the preoperative consent form is the clients.
D
a nurse is obtaining the blood pressure in a client's lower extremity. Which of the following actions should the nurse take? a. auscultate for the blood pressure at the dorsails pedis artery b. measure the blood pressure with the client sitting on the side of the bed c. place the cuff 7.6 cm (3") above the popliteal artery d. place the bladder of the cuff over the posterior aspect of the thigh
D
A nurse is reinforcing preoperative teaching with a client who is scheduled for arthroplasty in the next month & might require a blood transfusion. The client expresses concern about the risk of acquiring an infection from the blood transfusion. Which of the following suggestions should the nurse make? A. take epoetin before surgery B. Take iron supplements prior to surgery C. Request a family member to donate blood for you. D. Donate autologous blood before the surgery
D Autologous blood transfusion is the collection and reinfusion of the client's blood
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? A. Turn on the machine every 15 min B. Record only blood pressure readings needed for the 15-min intervals C. Obtain manual & automatic readings & compare them D. Disconnect the machine, &
D.
A nurse is providing teaching to a group of unit nurses about wound healing by secondary intention. Which of the following information should the nurse include in the teaching? A. The wound edges are well-approximated B. The wound is closed at a later date C. A skin graft is placed over the wound bed D. Granulation tissue fills the wound during healing
D.
A nurse is assessing the heart sounds of a client who has developed chest pain that becomes worse with inspiration. The nurse auscultates a high-pitched scratching sound during both systole and diastole with the diaphragm of the stethoscope positioned at the left sternal border. Which of the following heart sounds should the nurse document? A. Audible Click B. Murmur C. Third Heart Sound D. Pericardial Friction Rub
Pericardial Friction Rub
Inspection Palpation Ausculation Percussion Put them in the correct order
Inspection Auscultation Percussion Palpation
When does cognitive restoration occur: REM sleep or NREM sleep?
REM sleep
A community health nurse is preparing a campaign about seasonal influenza. Which of the following plans should the nurse include as as secondary prevention? 1. Educating parents of young children about dangers of influenza. 2. Screening groups of older adults in nursing care facilities for early influenza manifestations. 3. Holding a community clinic to administer influenza immunizations. 4. Finding rehabilitation programs for older adults who have complications from influenza.
Screening groups of older adults in nursing care facilities for early influenza manifestations.(Screening older adults who have some manifestations of illness to determine if they have influenza is an example of secondary prevention. Secondary prevention is focused on preventing complications of an illness or providing care to prevent illness from becoming severe).
A nurse is providing teaching to an older adult client who has constipation. What statement 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 had a mastectomy and has a self-suction drainage evacuator in place. Which of the following actions should the nurse take to ensure proper operation of the device?
collapse the device of air after emptying
What vitamins help fight wound infection and promote healing?
Vitamin C Zinc
what lab findings should the nurse expect for a patient who has a positive Chvostek's sign? A. decreased calcium B. decreased potassium C. increased calcium D. increased potassium
a
A patient has a sodium level of 125 mEq/L. What finding would you expect?
abdominal cramping
COVID-19: contact, droplet or airbone?
airborne
TB: contact, droplet or airbone?
airborne
What type of dressings promote healing in STAGE 3 and stage 4 pressure injuries?
alginate
A nurse is applying an ice bag to the ankle of a client following a sports injury. Which of the following actions should the nurse take? A. Leave the bag in place for 45 min. B. Fill the bag two-thirds full with ice. C. Place the ice bag uncovered on the client's ankle. D. Tell the client that it is expected to feel numbness when the ice bag is in place.
b
What are three risk factors for the development of hypocalcemia?
bariatric surgery thryoid cancer diarrhea
What is the BMI of someone underweight?
below 18.5
A nurse is collecting a urine specimen for C&S for a client who has UTI. The client has an indwelling urinary catheter in place. Which of the following action should the nurse take?
clamp the tubing below the collection port
Removing abdominal dressing: do you use clean gloves or sterile gloves?
clean gloves
What should the nurse perform during medication reconciliation?
compare the clients home medications with the providers perscriptions
MRSA: contact, droplet or airbone?
contact
what should you do after each use of a incentive spirometer?
cough deeply
A nurse is providing discharge teaching to a client who is recovering from lung cancer. The provider instructed the client that he could resume lower-intensity activities of daily living. Which of the following activities should the nurse recommend to the client? A. sweeping the floor B. shoveling snow C. cleaning windows D. washing dishes
d
What test provides the most accurate measure of a clients fluid status?
daily weight
What indication shows that treatment was successful after giving sodium chloride to a fluid volume deficit patient?
decrease in heart rate
What is an indication of fluid volume excess?
distended neck veins
Influenza: contact, droplet or airbone?
droplet
What precautions should you take with the rubella virus?
droplet
What is the most common clinical manifestation of hypernatremia?
dry swollen tounge
a nurse is called away for an emergency while conversing with a patient who is concerned about his medical diagnosis. the nurse returns to the patient promptly, as promised. what ethical principle is the nurse demonstrating?
fidelity (keeping promises)
What type of dressings promote healing in stage 4 or unstageable pressure injuries?
guaze
What type of dressings promote healing in stage 2 pressure injuries?
hydrocolloid
Patients with diabetes insipidus are at risk for what electrolyte imbalance?
hypernatremia
What is the most common clinical manifestation of hypomagnesemia?
hypertension
Patients with hypoparathyroidism are at risk for what electrolyte imbalance?
hypocalcemia
In order to make the ball rise in the incentive spirometer, should the patient inhale or exhale?
inhale
What faith stays with the dead body until burial occurs?
jewish faith
What drainage is thick yellow, green, or brown?
purulent exudate
What examination tests for balance?
rombers test
This drainage indicates plasma from the blood and appears clear to light yellow and watery.
serous exudate
what assessment finding should the nurse identify as an indication of hypovolemic shock for a patient who has abdominal trauma?
tachycardia
What route of measuring temperature would be used in a toddler who has a ear infection and diarrhea?
temporal
What is echinacea taken to promote?
the immune system
when lifting an object, where should you bend at?
the knees
What is the most common clinical manifestation of hypocalcemia?
tingling around the mouth
What type of dressings promote healing in stage 1 pressure injuries?
transparent dressings
