Fundamentals final kahoot

A nurse is teaching a client about snacks that are appropriate on a low-fat, low-sodium, and low-colesterol diet. Which of the following food choices by the client indicates the need for further teaching?

A slice of cheese

The supervising nurse is observing several different nurses. Which action will cause the supervising nurse to intervene?

draws up NPH first when mixing a short-acting & intermediate-acting insulin

eye drops

drop into the lower conjunctival sac

Your client has a uti. Which of the following symptoms would you expect her to be exhibiting?

dysuria

Cuff too small

false high reading

Which site should the nurse choose to provide a manToux TB skin test to her client?

forearm

changing linen

hold linen away from the body

A nurse is assessing a client who is 3 days postoperative following abdominal surgery and notes the absence of bowel sounds, abdominal distention, and the client passing no flatus. Which of the following conditions should the nurse suspect?

Paralytic ileus

A nurse is preparing to administer three liquid medications to a client with an NG tube with intermittent suction. Which of the following actions should the nurse take?

Pinch the tube prior to attaching the medication syringe.After detaching the NG tube from the suction tubing, the nurse should pinch or kink the tube to prevent distention from air entering the tube

Which conditions affect chest wall movement

Pregnancy, Obesity,Musculoskeletal abnormalities, Trauma, Neuromuscular diseases, Central nervous system alterations, Influences of chronic lung disease

What should you add to the diet to promote wound healing?

Protein

A nurse is reviewing a client's admission record. The nurse notes that there are prescriptions for several medications. Which of the following factors should the nurse recognize is of primary consideration when determining the schedule of administration?

Specific characteristics of the medications

Oral routes

Sublingual administration, Buccal administration

A nurse is caring for a client following the surgical placement of a colostomy. Which of the following statements indicates the client understands the dietary instructions?

"Eating yogurt can help decrease the amount of gas that I have."The client who has a colostomy can include yogurt into his diet to help reduce odors and intestinal gas.

A nurse is caring for a client who reports taking bisacodyl to promote a daily bowel movement. Which of the following assessment questions should be the nurse's priority?

"How long have you been taking the bisacodyl? "Bisocodyl is a stimulant laxative indicated for short-term use due to a risk of dependency. It is importantfor the nurse to determine the history, specifically the length of time the client has relied on thismedication for bowel elimination.

Which statement by the student nurse indicates the need for further education about medication administration?

"I should advise the certified medical assistant to administer intravenous medication."

A nurse is providing preoperative instruction to a client undergoing an open bowel resection at 1300 nextweek. Which of the following statements by the client indicates the need for further instructions?

"I will be able to eat solid food when I wake up from anesthesia." Clients who undergo open abdominal surgery will usually have an NG tube in place. The client will remain NPO until the nurse removes the tube. Once the nurse removes the tube, the client can start to drink clear liquids and progress to more solid fluids as the client is able to tolerate them.

A nurse is teaching a patient about medications. Which statement from the patient indicates teaching is effective?

"I will rotate the sites in my left leg when I give my insulin."

Which patient using an inhaler would benefit most from using a spacer?

A 25 year old with limited coordination of the extremities

The pt is to receive phenytoin (Dilantin) at 0900. When will be the ideal time for the RN to schedule a trough level?

08:30

The nurse is unfamiliar with the medication she is giving what should she to do?

1. Consult the medication reference book available on the unit. 2. A nurse must have knowledge about medications to administer them safely. The nurse should become familiar with the medication by looking it up it in the medication reference on the unit.

Which of the following is not an appropriate step to providing an Intramuscular injection with the z-track method? SATA

1. Displacing skin with the ulnar surface of your dominant hand 1-1 ½ inches. 2. Pinching the skin 3. Injecting at a 45 degree angle

Indwelling catheter

1. Hang the bag below the level of the bladder 2. Make sure there are no kinks 3. Use soap and water to clean perineum 3x a day 4. Tape the catheter to the inner thigh

How to Prepare an injection from a vial

1. If dry, use solvent or diluent as needed 2.Inject air into vial 3. Label multidose vials after mixing 4. Refrigerate remaining doses if needed

Oral care for unconscious patient

1. Turn pt on to the side in lateral position to prevent aspiration 2. Use water or alcohol-free mouth wash to rinse the client's mouth 3. Use a foam swab because lemon-glycerin swabs dry and irritate the mouth and can cause damage to the teeth.

How to prevent back injuries?

1. When lifting an object, spread your feet apart to provide a wide base of support. 2. Stand to the client as close as possible

Which of the following will help prevent constipation in a client? (Select all that apply)

1. eating raw vegetables 2. exercising

Which of the following procedures require the client to be lying in left sims position? (Select all that apply)

1. receiving a soapsuds enema 2. Receiving a suppository 3. Receiving a cleansing enema

RN is teaching the pt about caring for their new colostomy. Which is appropriate education?

1.Avoid moisturizing soap when cleansing the peristomal skin. 2.Empty your bag when it is half full 3.Make sure the pouch opening around the stoma is cut to the appropriate size

Which of the following are appropriate nursing actions when caring for a client with a chest tube? (SATA)

1.Maintain the drainage system below the client's chest 2.Watch for slow, steady bubbling in the suction-control chamber

Which of the following can cause hypoxia? (Select all that apply)

1.Shock 2.High Altitudes 3.Pneumonia

How to Prepare an injection from an ampule

1.Snap off ampule neck 2. Aspirate medication into syringe using filter needle 3. Replace filter needle with an appropriate size needle or needless device 4. Administer injection 36

A RN is following safety principles to reduce the risk of needlestick injury. Which actions will the nurse take? SATA

1.Use needleless devices whenever possible. 2.Use clearly marked sharps disposal containers. 3.Never force needles into the sharps disposal.

Limit of acetaminophen per day

3-4 g a day

A provider prescribes aspirin 650 mg every 4 hours PO when febrile. For which patient will this order be appropriate?

62 year old with a high fever from an infection

Which medication will be crushed by a nurse caring for a client with difficulty swallowing?

Acetaminophen extra strength

Nurse's role in medication administration

Administer medications correctly, Closely monitor effects, Provide patient education, Determine time, Determine correct medication ordered, Assess patient ability to self-administer

A nurse is preparing to administer a pre-packaged oral medication to a client and complete the finalmedication check. At which of the following times or places should the nurse perform this final check?

At the client's bedside before administration. The nurse should perform the final medication check at the client's bedside while reviewing the package's label

When would the nurse have the laboratory obtain a blood sample to determine the peak level of an antibiotic administered by intravenous piggyback (IVPB)?

Between 30 and 60 minutes after a dose

Signs of fluid volume excess

Bounding pulse, Edema

Which of the following are signs of worsened hypoxia?

Bradypnea

A nurse is caring for a client with an indwelling urinary catheter. Which of the following actions should the nurse take to prevent infection?

Check the catheter tubing for kinks or twisting. The nurse should check the catheter for twisting or kinks in the tubing. These obstructions can affect the flow of urine causing pooling in the tubing that could backflow into the bladder

When is orotracheal or nasotracheal suctioning appropriate?

Client is unable to clear secretions by coughing

Intramuscular Injection Sites

Ventrogluteal Vastus lateralis Deltoid

A nurse is providing dietary instructions for a Asian-American client and is gazing at the floor during theinstructions. Which of the following actions should the nurse take to demonstrate culturally sensitive nursing care?

Continue with the discussion A client from this culture might consider direct eye contact, close personal space, and touching to be impolite, aggressive, or disrespectful. By remaining silent and avoiding eye contact, the client could be demonstrating respect for the nurse. The nurse should continue with the dietary teaching while also avoiding eye contact and assess comprehension throughout the discussion.

Home oxygen therapy

Cotton clothing to avoid static

Incentive spirometer use

Cough after using to help move the secretions

A nurse is caring for a client that is postoperative following abdominal surgery. The surgeon initiallyprescribes a clear liquid diet. Which of the following items should the nurse include on the client's lunchtray?

Cranberry juice Cranberry juice is an acceptable component of a clear liquid diet, along with apple juice and grape juice

Which of follow is an effect of aging on the cardiopulmonary system?

Decreased airway clearance

Age related changes

Decreased cardiac output. Heart takes longer to return to normal after exercising.

Which nurse's action would prevent aspiration when administering medications through a nasogastric tube?

Verify placement of the nasogastric tube

Which information must be clearly described in the medication administration record (MAR) before administering a medication? Select all that apply.

Dosage and route Client's full name Time to be administered Frequency of administration Full name of prescribed medication

A nurse is developing an instruction plan for a client with an ileostomy and will require stoma care. Which ofthe following information should the nurse include?

Empty the pouch when it is 1/2 full. The nurse should instruct the client to empty the pouch when it is 1/3 to 1/2 full

A client needs assistance in eliminating an anesthetic gaseous medication (nitrous oxide). Which action will the RN take

Encourage the patient to cough and deep-breathe.

A 25-year-old client is angry and has several verbal altercations with other clients and then refuses to take prescribed medications. Which intervention is best?

Explain the purpose and benefits of the medication but allow the client to refuse the medication.

A patient refuses medication. Which is the nurse's first action?

Explore with the patient reasons for not wanting to take the medication.

NG tube with enteral feeds

HOB 30-45 degrees to prevent aspiration

Which of the following statements by the client about incentive spirometry (IS) would require follow up by the nurse?

I shouldn't ask for pain medication before using my Insentive spirometer

paralytic ileus

Immobile bowel. Bowel sounds are absent and the abdomen is distended.

Colostomy care

cleanse skin with warm water around the stoma

Serosanguineous

clear and red fluid mixed-pink

serous

clear drainage

purulant

containing pus-yellow, green or brown drainage

Which of the following could constitute inappropriate injection technique for a subcutaneous injection?

Massages the site after injection

A nurse is completing a client's history and physical examination. Which information would the nurse document as subjective data?

Nausea Subjective data include information that only the client can perceive and report. The nurse cannotdetermine that the client feels nauseated

Intramuscular

Needle diameter - 18-25 gauge Needle length- 5/8- 1 1/2 inch Needle angle - 90 degrees

subcutaneous

Needle diameter - 25-27 gauge Needle length - 3/8- 5/8 inch Needle angle - 45-90 degrees

Intradermal

Needle diameter - 25-27 gauge, Needle length - 1/2- 5/8 inch Needle angle - 5-15 degrees

Subcutaneous insulin

Needle diameter - 25-31 gauge Needle length - 5/16-1/2 inch Needle angle - 45-90 degrees

The charge nurse delegates to the health care team the task to provide an intravenous (V) medication to a group of people who were diagnosed with gastroenteritis because of food poisoning. Which health care team member is suitable to provide medication in this situation?

Registered nurse (RN)

A nurse is instructing a group of clients regarding nutrition. The teaching should state that which of the following groups of foods contains the highest level of carbohydrates?

Rice, potatoes, and oranges

CRITICAL THINKING

Right medication, Right dose, Right patient, Right route, Right time, Right documentation, Right indication

A nurse is caring for a client that was ordered a stool specimen collected. Which of the following actions should the nurse take when obtaining the specimen?

Send specimen container immediately to the lab. The nurse should label the specimen contain and send it immediately to the laboratory. A delay in transport can result in altered laboratory findings

A nurse is discussing good food choices with a client who is recovering from an exacerbation of inflammatory bowel disease and is to start a low-lactose diet. Which of the following foods is the best choice for the client?

Soy milk

Hypovolemic shock signs

Tachycardia Cool and clammy skin Decreased urine output

The nurse is administering medications to several patients. Which action should the nurse take?

Tell a pt after a corticosteroid inhaler treatment to rinse mouth w/ water

A nurse is administering nasal decongestant drops for a client. Which of the following actions should the nurse take?

Tell the client to blow her nose gently before the instillation.Prior to instillation, the nurse should instruct the client to blow her nose gently. This action will help remove any secretions or crusts that could interfere with the distribution and absorption of the medication.

A nurse is preparing an instruction plan for a client with chronic constipation secondary to irregular bowel habits. Which of the following should the nurse plan to include in the instructions?

The client should follow a high-fiber diet to establish bowel regularity

For which circumstance would the nurse use the Z-track technique to administer a medication?

The medication is irritating to subcutaneous tissue and skin.

Afterload refers to:

The resistance to left ventricle ejection

RN is preparing insulin injection in which both regular & NPH will be mixed. Into which vial should air be injected first

The vial of NPH

A nurse is instructing a group of clients about nutrition and eating foods high in iron. The nurse should include that which of the following aids in the absorption of iron?

Vitamin C Vitamin C enhances the body's absorption of iron.

worried before procedure

ask what worries them

sanguineous

bright red blood drainage

Which nutrient is the body's most preferred energy source?

carbohydrate

no urine output from foley

check catheter for kinks

urine collection from catheter

clamp the tubing below the port to allow fresh urine to flow

Enema insertion

lubricate 2-3 inches of the tipposition on left side simsinsert 3-4 inches in rectumenema container should be help up 18 inches STOP IF SUDDEN/SEVERE PAIN OR CRAMPING

rectal temperature

most accurate

RN notes yellow drainage present on gauze that was in the client's wound. How would the nurse document this drainage?

purulent

restraints

renew order every 24 hours

Which of the following is the most accurate method of bedside confirmation of placement of a small-bore NG tube?

test the ph of withdrawn gastric contents

decrease the risk of falls

use of gait belt

intramuscular injection to an obese client

ventrogluteal injection-the side of the hip between the iliac crest and anterior iliac spine. V shape. Given at a 90 degree angle

Transferring a patient from the bed to the wheelchair

wheelchair at 45 degree angleclient should lean forward from the hipsnurse should be on the weaker side of the client nurse should have a wide stance

secondary intention wound healing

when a wound is allowed to remain open and heal by granulation