Fundamentals

The nurse is assessing a client with abdominal complaints. The nurse performs deep palpation of the abdomen for which reason?

Detect abdominal masses.

A hospital nurse is coming on shift for a night shift and is receiving a change-of-shift report from a colleague. The colleague states that one client refused a prepared medication that was scheduled for 1800. The colleague has left the medication in a paper cup in the client's drawer on the medication cart and asks the nurse to administer the medication when the client goes to bed for the night. How should the nurse respond to this scenario?

Discard the medication and administer a dose of the correct drug from a labeled container.

The nurse is teaching a client how to instill multiple ophthalmic medications. Which teaching points will the nurse include? Select all that apply.

Dispose the medication after 28 days to prevent bacterial contamination Wait 5 minutes between administration of different eye drops There are devices available that can help you with instilling the drops

A home care client has an indwelling catheter connected to a leg bag. What can the nurse recommend to help prevent development of a urinary tract infection?

Empty the leg bag at regular intervals.

The nurse is preparing to perform a nutritional assessment for a client. Which question would be most appropriate to use when initiating the assessment?

"Can you tell me what you've eaten in the last 24 hours?"

An older adult woman in a long-term care facility has fallen and sustained a hip fracture. The nurse would ask which question(s) to assess possible causes of the fall? Select all that apply.

"Did you have pain in your hip prior to the fall?" "Can you tell what you were doing before you fell?" "Is it possible you may have tripped over a rug or a cord?" "Did you experience dizziness prior to the fall?"

A home health nurse is visiting a client who is receiving chemotherapy for cancer treatment. What question would the nurse ask to assess for complications or side effects of chemotherapy related to skin, nails, or hair?

"Have your mouth and lips become sore and inflamed with ulcers?"

A nurse must perform an integumentary inspection on a client. Which statement most effectively explains why the nurse will be assessing the client's skin?

"I am inspecting your skin to get a baseline of your skin and to check if any conditions require treatment."

A client who has been reluctant to have the hair shampooed for 1 week tells the nurse, "I do not want you to shampoo my hair. It does not need washing." What response by the nurse is appropriate?

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

The nurse is caring for a client who reports constipation and is presently in the bathroom attempting to have a bowel movement. The client presses the call bell and tells the nurse that about feeling dizzy. What education should the nurse provide the client about this condition?

"This occurs when bearing down and decreasing blood flow to the heart; then when you stop, the blood flow returns in a larger amount."

A client is preparing to mobilize for the first time following the surgical removal of a bunion on her left foot. How should the nurse instruct the client to ambulate with her crutches?

"Try to avoid putting too much pressure on your armpits with the tops of the crutches."

The nurse is teaching the caregiver of a toddler about the importance of calcium to help the toddler's teeth and bones develop properly. Which client statement reflects that nursing teaching has been effective?

"Vitamin D helps calcium absorption."

The nursing assistant is preparing to help the client make a lateral transfer from the bed to a stretcher. The client informs the nurse that the client is able to move onto the stretcher without the nurse's help. What is the nurse's best response?

"You are free to move onto the stretcher without assistance, but I will supervise for your safety."

A client has just returned from surgery with a Foley catheter in place. The nurse anticipates that the catheter will be removed within what time frame after the operation?

24 hours

A nurse is preparing to administer an intramuscular injection to a client. Which would be appropriate for the nurse to do to reduce discomfort? Select all that apply.

Apply pressure to the site when withdrawing the needle. Use the Z-track technique. Apply ice to the site before administration.

A nurse is caring for a restrained client who has suicidal tendencies. How should the nurse intervene to decrease the risk of injury?

Assess for circulation, movement and sensation

A nurse provides a back massage to a client before bedtime to promote relaxation. What is the nurse's priority action before beginning this intervention?

Assess the client for presence of pain

An older adult client is in the hospital following an intestinal diversion with an ileostomy on the right upper quadrant and a mucous fistula. What is the most important nursing action in the care of this client?

Assess the color of the stoma.

A client has been in the hospital for the past 10 days following the development of an infection at her surgical incision site. Each morning, the client reports overwhelming fatigue and has told the nurse, "I just can't manage to get any sleep around here." How should the nurse first respond to this client's statement?

Assess the factors that the client believes contribute to the problem.

The nurse is caring for an adult client that had a cerebrovascular accident (CVA) 1 month ago. How would the nurse assist the client in relearning self-care?

Assist the client in dressing oneself after offering alternative techniques

A nurse is caring for a client with long hair. What intervention will best promote care of long hair during hospitalization?

Brushing it out then braiding or tying it back.

A client tells the nurse that he takes laxatives every day but is still constipated. The nurse's response is based on which reasoning?

Habitual laxative use is the most common cause of chronic constipation.

A nurse is withdrawing a dose of heparin from a vial and notices that a significant volume of air is mixed with the medication that is now in the syringe. How can the nurse increase the pressure in the vial to reduce the chance of bubbles in the syringe?

Inject air into the vial equal in volume to the medication that will be withdrawn.

A nurse provides care for an adolescent who is diagnosed with mononucleosis. Which crucial information does the nurse include in client education about the condition? Select all that apply.

It is important to practice safe sex because a form of mononucleosis can be transmitted through sexual contact. Mononucleosis is called the "kissing disease" so refrain from kissing. Because mononucleosis is spread through saliva, do not share food, drinks, or silverware. Cover coughs or sneezes to reduce the risk of spreading infection. The Epstein-Barr virus (EBV) causes mononucleosis.

A nurse is caring for a client who has been diagnosed with insomnia. Which nursing intervention would help the nurse relieve the client's condition?

Maintain a calm and quiet environment free from noise.

A nurse is caring for a client who has been prescribed codeine, an opioid medication to relieve severe postoperative pain. Which responsibility does the nurse have to complete when handling opioid medications? Select all that apply.

Maintain an accurate account of the use of the medication. Record each medication used from the stock supply. Count each opioid medication at the change of each shift.

A home care nurse visits a client who is confined to bed and is cared for by an adult child with substance use disorder. The home is cluttered and unclean, and the nurse notes that the client is wet with urine, has dried feces on the buttocks, and shows signs of dehydration. After caring for the client, the nurse contacts the health care provider and reports the incident to Adult Protective Services. What ethical principle is the nurse practicing?

Nonmaleficence

In preparing to administer a drug to a client, the nurse has pierced a multi-use vial of medication. What is the appropriate nursing action?

Place the date on the vial and retain for future use. (Multi-dose vials should be dedicated to a single patient whenever possible)

Which intervention would the nurse implement to prevent infections in a client who is neutropenic as a result of chemotherapy and radiation therapy?

Protective isolation precautions

A nurse is preparing to perform oral care for a client who has full dentures. Which action(s) should the nurse take? Select all that apply.

Provide privacy while the client removes dentures from the mouth Use a toothbrush and paste to gently brush all surfaces Rinse the dentures with water or normal saline if the client is dehydrated. Place paper towels or a washcloth in the sink to prevent damage if the dentures are dropped during cleaning

The nurse is caring for a client with hemorrhoids. To facilitate a rectal examination, into which position will the nurse place the client?

Sims'

The nurse is assessing an adult client who is experiencing heart disease. The client has stated a belief that stress at work is causing the problem. What information is important for the nurse to assess? Select all that apply.

Tell me about your job? How many hours do you work each week? What shift do you work?

A nurse observes that a client coughs and chokes when eating. What instructions should the nurse prepare for this client?

Tell the client to chew his food very thoroughly

An 18-year-old client is brought to the urgent care clinic reporting severe left leg pain. Which assessment(s) should the nurse prioritize for this client? Select all that apply.

Tenderness to palpation Skin color Pedal pulses Temperature of skin

A client has had a total knee replacement and is receiving care that includes learning to walk with a walker. What level of prevention is most applicable to this client?

Tertiary prevention

The nurse has completed a change of a client's bedding while the client is seated in a wheelchair. When removing the bedding, what action best maintains the principles of infection control?

The one where the nurse is putting the bedding on the bed. The nurse should avoid placing it on surfaces where it could transmit microorganisms (floor and chairs)

The nurse is preparing to insert an intravenous catheter into a client. Which infection control procedure will the nurse use to ensure safe client care?

Use a sterile intravenous catheter.

The nurse performs discharge teaching for the family of an older adult client with a visual impairment and decreased mobility. Which instruction would the nurse give to help prevent falls in the client's home?

Use night-lights in bedrooms and bathrooms.

During defecation, the client experiences decreased cardiac output related to the Valsalva maneuver. After the Valsalva maneuver, the nurse assesses the client's vital signs and expects to observe which of the following?

an increase in the client's blood pressure

After reviewing the client's chart, the nurse notes that the client has been ordered a clear liquid diet. Which meal tray would the client be allowed to eat?

bouillon, apple juice, and gelatin

The nurse is teaching fire safety to members of a community. When a community member asks which type of fire extinguisher would be appropriate to put out an electrical fire, what will the nurse identify?

class C

The nurse is preparing to administer a client's intramuscular injection and intends to use the technique shown. What potential benefit of this technique should the nurse describe?

decreased irritation and pain in subcutaneous tissue

A nurse is caring for a client with urinary incontinence. When providing continence training to the client, what should the nurse tell the client about the Credé maneuver?

exerting manual pressure on the abdomen at the location of the bladder, just below the navel. Patients can learn to perform the maneuver on themselves as it is simple to do.

A nurse is preparing to move a client up in bed. How can the nurse best demonstrate the principles of correct body mechanics?

facing the direction of movement

During the physical assessment of a client, the nurse uses the head-to-toe approach. What are the advantages of this approach? Select all that apply.

helps prevent overlooking some aspect of data collection reduces the number of position changes required of the client Takes less time because the nurse doesn't have to constantly move around the client. Explanation: Findings tend to be clustered, making the problem more easily identifiable in the body systems approach. However, in using the body systems approach, the same areas of the body are examined several times before the assessment is completed.

The nurse obtained the above assessment data for a newly admitted client. The nurse prioritized that this client has a risk for falls. What information in the client data places the client at risk? Select all that apply.

history of a fall administration of oxycodone fractured leg

A nurse is ambulating a client who has had a cerebrovascular accident (CVA). The client has paresis on the right side of the upper body. Where would the nurse stand to walk the client?

on the weak side

A nurse is taking care of an older adult client who demonstrates good mobility but is unable to stand for long periods of time secondary to muscle weakness. What action will the nurse use to facilitate the client's self-care and safety?

provide a shower chair

Which action by the unlicensed assistive personnel (UAP) requires intervention from the nurse when providing care to an older adult client who is at risk for falls?

provides slippers for ambulation

A client describes pain in the lower leg and has been diagnosed with a herniated lumbar disk. The pain in the leg is what type of pain?

referred pain

The home health nurse is assisting a client and the family in planning the client's return to work after an extensive illness. On which level of Maslow's hierarchy of basic needs does the client's need for self-fulfillment fit?

self-actualization

A nurse suspects that a client has abdominal ascites and prepares to assess the abdominal girth. How should this assessment be completed?

stretching a tape measure around the largest diameter and making guide marks on the skin

A nurse is examining the urine specimen of a dehydrated client. What is a characteristic odor of the urine voided by a dehydrated client?

strong