Fundamentals Lab Exam Final
Which degree should the injection be given in an IM injection?
90°
Oral temperature range
97.6-99.6 F
Rectal temperature range
98.6-100.6 F
How far do you insert a rectal thermometer?
1-1.5 inches
A nurse is caring for a client who is receiving oxygen at 2 L/min via a nasal cannula. The nurse recognizes the client is receiving which of the following inspired oxygen concentration?
28%
How much liquid soap should the nurse use when performing hand hygiene?
4-5 mL
Which degree should the injection be given in a subQ injection?
45°
A provider prescribes a sublingual medication for a client who has an NG tube in place. Which of the following actions should the nurse take?
Administer the medication under the client's tongue.
A nurse is providing teaching to a group of unlicensed assistive personnel (UAP) about hand hygiene. Which of the following statements by one of the UAPs indicates a need for further teaching?
As long as I change gloves between clients, it is not necessary to wash my hands
A nurse is preparing a client for ambulation. Which of the following actions should the nurse take to determine the client's level of strength?
Ask the client to push her feet against the nurse's palms
Before administering a medication to a client, the nurse must identify the client. Which of the following methods of identification should the nurse use?
Ask the client's full name and date of birth.
A nurse is assessing a client's radial pulse and determines that the pulse is irregular. Which of the following actions should the nurse take?
Assess the apical pulse for a full minute.
A nurse is preparing to administer a soapsuds enema to an adult client. Which of the following actions should the nurse take?
Assist the client to the left Sims' position
A nurse is preparing to administer a pre-packaged oral medication to a client and complete the final medication check. At which of the following times or places should the nurse perform this final check?
At the client's bedside before administration
A nurse is helping an older adult client ambulate in the hallway for the first time since admission. The client has brought her standard walker from home. To ensure proper use of the walker and the safety of the client, which of the following actions should the nurse take?
Check that the client lifts the walker and then places it down in front of her.
A nurse is caring for a client who came to the emergency department with abdominal distention and is now on the medical-surgical unit with an NG tube in place to low gastric suction. The client is reporting anxiety, discomfort, and a feeling of bloating. Which of the following actions is the nurse's priority?
Check to see if the suction equipment is working
A nurse is caring for a client who is receiving oxygen therapy via a nasal cannula. The nurse explains to the client that this method of oxygen delivery does which of the following?
Delivers a low concentration of oxygen
A nurse is preparing to transfer a client from a bed to a chair. Which of the following actions should the nurse take first?
Determine if the client can bear weight.
A nurse is preparing a client's evening dose of risperidone when the tablet falls on the countertop. Which of the following actions should the nurse take?
Discard the tablet and obtain another dose of medication.
Which of the following findings should the nurse identify as an indication of an infiltration?
Edema in the palm of the hand
The client is receiving continuous enteral feedings via a gastrostomy tube due to an inability to swallow. Which of the following is the priority action by the nurse?
Elevate the head of the client's bed 30° to 45°
A nurse is assisting an older adult client who sometimes loses her balance while walking. Which of the following devices should the nurse use when helping the client ambulate?
Gait belt
A nurse is removing personal protective equipment (PPE) after giving direct care to a client who requires isolation. Which of the following PPE items should the nurse remove first?
Gloves
A nurse is preparing to administer a cleansing enema to a client. Which of the following actions should the nurse take?
Hold the container of solution 30 cm (12 in) above the anus.
A nurse is preparing to administer ophthalmic solution to a client. Which of the following actions should the nurse take?
Hold the ophthalmic solution 2 cm (3/4 in) above the lower conjunctival sac.
A nurse is assisting a client who has received crutches in an urgent care center following a foot injury. Which of the following statements should the nurse identify as an indication that the client needs further teaching?
I have a set of my brother's crutches in my basement I can also use
A nurse is reinforcing teaching with a client about using transdermal patches at home. Which of the following statements should the nurse identify as an indication that the client understands the teaching
I will clean and dry the area before applying the patch.
A nurse is teaching a client's adult son about how to position the client when administering enteral feedings at home. Which of the following statements by the son indicates an understanding of the teaching?
I will have him sit in his chair during the feeding
A nurse is providing teaching to a new nurse about caring for clients with restraints. Which of the following statements by the new nurse indicates an understanding of the teaching?
I will tie a restraint to the portion of the bed that moves when the head of the bed is moved
A nurse is teaching an unlicensed assistive personnel (UAP) about using personal protective equipment while caring for clients. Which of the following statements should the nurse identify as an indication that the UAP understands the instructions?
I will wear gloves and a gown when bathing a client who has open skin lesions
A nurse instructs a female client about collecting a midstream urine sample. Which of the following client statements indicates an understanding of the procedure?
I'll use the cleansing wipe from front to back
A nurse is assisting a client during ambulation when the client begins to fall. Which of the following actions should the nurse take?
Lower the client to the floor
A nurse is preparing a sterile field. Which of the following actions should the nurse identify as contaminating the field?
Opening a sterile package over the middle of the sterile field Opening the sterile tray by first unfolding the flap closest to his body
A nurse is caring for a client who has an infection. The nurse should use which of the following strategies to prevent the transmission of the client's infection?
Performing hand hygiene before, during, and after direct contact with the client
A nurse is preparing to administer three liquid medications to a client who has an NG tube with intermittent suction. Which of the following actions should the nurse take?
Pinch the tube prior to attaching the medication syringe
Which of the following techniques should the nurse use to locate the deltoid muscle?
Place one finger across the acromion process and measure 3 finger spaces below to the midpoint and center of the lateral aspect of the upper arm
A nurse in a long-term care facility is observing an unlicensed assistant personnel (UAP) changing the linen for a client who has fecal incontinence. Which of the following actions indicates that the UAP understands the principles of infection control?
Places clean linen that touched the floor in the soiled linen bag
A nurse is caring for a client who has returned to the unit following a surgical procedure. The client's oxygen saturation is 85%. Which of the following actions should the nurse take first?
Raise the head of the bed
A nurse is preparing a sterile field. Which of the following actions should the nurse perform when opening the sterile pack?
Reach around the pack and open the top flap away from the body.
A nurse is teaching a new group of unlicensed assistive personnel (AP) about the importance of hand hygiene. Which of the following statements should the nurse include?
Rub all surfaces of your hands with an alcohol rub for 20 to 30 seconds
Prehypertension range
Systolic: 120-139 Diastolic: 80-89
A nurse is assessing a client who has a wrist restraint applied. For which of the following findings should the nurse loosen the restraint
The client's hand is cool and pale.
A nurse is providing preoperative teaching for a client who will undergo surgery. The nurse explains that the client will wear antiembolism stockings during and after the procedure. When the client asks what the stockings do, which of the following responses should the nurse make?
They improve your circulation to keep blood from pooling in your legs
A nurse on a medical unit is teaching a group of unlicensed assistive personnel about handling clients' bed linens safely. Which of the following instructions should the nurse include?
Tie linen bags securely at the top.
A nurse is caring for a client who receives intermittent enteral feedings through an NG tube. Before administering a feeding, the nurse should measure the gastric residual for which of the following purposes?
To identify delayed gastric emptying
A nurse is providing oral care for a client who is immobile. Which of the following actions should the nurse take?
Turn the client on his side before starting oral care.
A nurse is preparing to move a client who is only partially able to assist up in bed. Which of the following methods should the nurse plan to use?
Two nurses using a friction-reducing device
A nurse is orienting a new unlicensed assistive personnel (UAP) to the unit. For which of the following actions should the nurse INTERVENE?
Washes and rinses her hands for 10 seconds
When should restraints be used?
as a last resort
What does a stool test for guaiac test for?
blood
Which site is used to auscultate blood pressure
brachial
A nurse is preparing to measure a client's level of oxygen saturation and observes edema of both hands and thickened toe nails. The nurse should apply the pulse oximeter probe to which of the following locations?
earlobe
How to assess a patient for respirations
gently place the pt.'s hand in a relaxed position over the upper abdomen
Hypertension range
greater than 140/90
The patient has been sleeping and has been lying on his right side. The nurse is ready to take his temperature using a tympanic thermometer. She needs to insert the thermometer into which ear?
left ear
How should restraints be tied?
quick release knot
When inserting a rectal thermometer, the nurse encounters resistance. The nurse should
remove the thermometer and reinsert it gently
What does phlebitis feel like?
warm to the touch