fundamentals of nursing

A registered nurse is teaching a nursing student about how to communicate with a client who is cognitively impaired. Which statements made by the nursing student indicate a need for further education? Select all that apply.

- i should use visual cues - i should speak in a normal tone of voice - i should face the client so that he or she can see my mouth

A nurse is caring for a client who sustained skin injuries 3 days ago. Which changes can be noticed by the nurse in the client? Select all that apply.

- local edema - erythema

A client with dementia is admitted with a fractured hip after a fall at home. The client's family member witnessed the fall. Four hours after admission, the client's blood pressure increases to a moderately severe hypertensive level. The client pulls on the bedclothes continuously. The client's family member asks for pain medication for the client. What does the nurse concludes?

The client may be in pain and unable to respond appropriately.

After assessing a client's vision, the nurse observes the client has difficulty seeing objects that are far away. Which condition does the nurse suspect the client is experiencing?

myopia

Which type of debridement is most often used to quickly remove large amounts of a client's nonviable tissue?

surgical

A nurse is caring for a client with diarrhea. The nurse anticipates a decrease in which clinical indicator?

tissue turgor

The nurse reviews a medical record and is concerned that the client may develop hyperkalemia. Which disease increases the risk of hyperkalemia?

end stage renal failure

A client complains of pain. Which question asked by the nurse are most appropriate to assess the nature of the pain?

"Can you describe your pain to me?"

The primary healthcare provider prescribes an adrenergic agonist to a client with increased intraocular pressure. Which question is priority that the nurse should ask the client?

"Do you take antidepressants?"

The nurse is assessing a client with arthritis. Which statement made by the client indicates a precipitating factor that is an intellectual standard for critical thinking?

"I run for 30 minutes every day; this exercise increases my pain.

The nurse teaches a client about cleaning the skin to prevent pressure ulcers. Which statement made by the client indicates the nurse needs to follow up?

"I should apply powders or talc on a perineum wound."

What instruction would the nurse be most likely to give a client with reduced sensory perception to prevent injury from scalding?

"Use a bath thermometer."

The nurse teaches a nursing student about the discharge instructions to be given to a post-operative client. Which statement made by the nursing student indicates the nurse needs to intervene?

"you should use a saline solution on non oozing wounds"

The registered nurse is teaching a nursing student about interventions that reduce the risk of pressure ulcers in a client. Which statements made by the nursing student indicate effective learning? Select all that apply.

- "I will elevate the head of the client's bed to 30 degrees." - "I will instruct the client to take baths in lukewarm water." - "I will ensure that the client's fluid intake is 2000 to 3000 mL/day."

What are the roles of an unlicensed assistive personnel in skin care? Select all that apply.

- To assist the client in bathing - To apply wet dressings to the skin - To report changes in the skin appearance

Which intrinsic factors may contribute to falls in older adults? Select all that apply.

- deconditioning - impaired vision

A nurse is caring for a client with quadriplegia. Which nursing intervention will decrease the occurrence of pressure ulcers?

A nurse is caring for a client with quadriplegia. Which nursing intervention will decrease the occurrence of pressure ulcers?

An older client with macular degeneration comes to the eye clinic. Which response reported by the client does the nurse identify as consistent with the diagnosis?

Cannot see objects in the center of the visual field

A nurse applies a cold pack to treat an acute musculoskeletal injury. Cold therapy decreases pain by doing what?

Causing local vasoconstriction, preventing edema and muscle spasms

The nurse assesses an elderly client with a diagnosis of dehydration and recognizes which finding as an early sign of dehydration?

Change in mental status

A nurse is caring for a newly admitted client in a long-term care facility. The nurse notes that the client has a decreased attention span and cannot concentrate. The nurse suspects which effects of sensory deprivation?

Cognitive response

A client who experienced extensive burns is receiving intravenous fluids to replace fluid loss. The nurse should monitor for which initial sign of fluid overload?

Crackles in the lungs

A client reports diminished sensations of pain, touch, and temperature on the skin. The nurse touches the skin and finds it cool. Which skin changes should the nurse relate to the client's findings?

Decreased blood flow to the skin

A client in a hospice home care program is experiencing severe pain. Morphine has been prescribed for pain management. Which information should the nurse plan to explain to the client in preparation for this pain management regimen?

Dosages of the drug will be given automatically at regular intervals around the clock.

While assessing an older adult, the nurse observes visual impairment in the client. Which technique should the nurse use to communicate?

Encourage the older adult to use assistive devices such as glasses

What is the nurse assessing when checking the cardinal positions from the image?

Extraocular muscle function

A client's wound is healing. Which event occurs in the proliferative phase of wound healing?

Formation of "granulation" tissue

The nurse is assessing a client with impaired hearing. Which action of the nurse is most important for establishing a good communication with the client?

Getting the client's attention before speaking

A client who had thoracic surgery complains of pain at the incision site when coughing and deep breathing. What action should the nurse take?

Instruct the client to splint the wound with a pillow when coughing.

A client who is legally blind is admitted to the hospital for surgery. Which nursing action is most appropriate when caring for this client?

Keep the furniture in the same location in the room

Which practice would be suitable in the prevention of a pressure ulcer?

Keeping the client's skin directly off plastic surfaces

A 65-year-old client tells the nurse, "I see some particles that float within my field of vision." What may be the cause of this condition?

Liquefaction and detachment of the vitreous membrane

Which action of the nurse would be most important to convey interest in starting a conversation with a client who has hearing loss?

Making eye contact with the client

A pain scale of 1 to 10 is used by a nurse to assess a client's degree of pain. The client rates the pain as an 8 before receiving an analgesic and a 7 after being medicated. What conclusion should the nurse make regarding the client's response to pain medication?

Medication is not adequately effective

After surgery for a fractured hip, a client states, "I don't remember when I have ever been so uncomfortable." What should the nurse's initial response be?

Perform a complete pain assessment

Which serum laboratory values in a client with urinary problems may indicate the risk of developing muscle weakness and cardiac arrhythmias?

Potassium of 7.02 mEq/L (7.02 mmol/L)

Which key feature does the nurse associate with a stage 2 pressure ulcer?

Presence of nonintact skin

A client has sensorineural hearing loss. Which finding in the client's history will alert the nurse to the most likely cause of the sensorineural hearing loss?

Prolonged exposure to noise

A hospice client who has severe pain asks for another dose of oxycodone. What is the nurse's primary consideration when responding to the client's request?

Reduce the client's pain

What is the mechanism of action for wet-to-damp saline-moistened gauze for wound debridement?

Removing the necrotic tissue mechanically

When a nurse requests that a client's pain intensity be rated on a scale of 0 to 10, the client states that the pain is "99." How does the nurse interpret the client's behavior?

Requires an intervention immediately

A client is receiving oxycodone postoperatively for pain. The healthcare provider's prescription indicates that the dose should be administered every 3 hours for eight doses. What should the nurse assess before administering each dose of oxycodone?

Respiratory rate and level of consciousness

A nurse is monitoring a client who is receiving an intravenous (IV) infusion of normal saline. What is a serious complication of IV therapy?

Shortness of breath with crackles

A client who had a total hip replacement is receiving continuous regional analgesia. The nurse recognizes what as the benefit of this treatment over conventional methods?

Systemic side effects are minimal

A client's serum potassium level has increased to 5.8 mEq/L (5.8 mmol/L). What action should the nurse implement first?

Take vital signs and notify the healthcare provider.

Which of the following nursing interventions promotes perfusion and healing of the surgical wound for an older adult?

The nurse should keep the client adequately hydrated

The registered nurse finds that a client cared for by a student nurse has developed an infection. Which action of the student nurse does the registered nurse suspect to be the cause of infection?

Use of a wet dressing

A client who has a long leg cast for a fractured bone is to be discharged from the emergency department. When discussing pain management, when does the nurse advise the client to take the prescribed as-needed oxycodone?

When the discomfort begins

After abdominal surgery a client reports pain. What action should the nurse take first?

determine the characteristics

A nurse is teaching an older adult client about managing chronic pain with acetaminophen. Which client statement indicates that the teaching is effective?

"I have to be careful about which over-the-counter cold preparations I take when I have a cold."

The primary healthcare provider treats a client with a pressure ulcer. While assessing the client, the nurse identifies exposed bone and tendons. Which stage does the nurse document for this pressure ulcer?

4

The client's serum sodium is 123 mEq/L (123 mmol/L). Which prescription should the nurse question?

Administer intravenous saline (NS) at 125 mL/hr

The registered nurse is teaching a student nurse about nursing roles while caring for a client with skin conditions. Which task could be delegated to a licensed practical nurse in this situation?

Applying dressings and administering medications

Which instruction from the nurse to an 80-year-old client with thinning of a subcutaneous layer would be most beneficial?

Dress warmly in cold weather

After an above-the-knee amputation of a right leg, a client reports pain in the right foot. The nurse should inform the client that phantom limb pain is the result of what?

Nerve endings in the limb that are still intact and react to stimuli

Which assessment finding in a client signifies a mild form of hypocalcemia?

Numbness around the mouth

The primary healthcare provider confirms that the client has myopia. Which type of test did the nurse perform to help the primary healthcare provider reach this conclusion?

Snellen eye chart

The nurse is assessing a client who had knee replacement surgery. Which assessment finding gathered by the nurse is an example of subjective data?

The client's pain is 7 on a scale of 1 to 10

When should the nurse use hypoallergenic tape or Montgomery straps as the best practice in postoperative skin care?

When protecting the fragile skin of the older client

The nurse is caring for a client who is in pain following surgery. The nurse informs the primary health care provider about the client's request for pain medication. What is the role of the nurse in this situation?

advocate

A nurse is caring for an older adult who is taking acetaminophen for the relief of chronic pain. Which substance is most important for the nurse to determine if the client is taking because it intensifies the most serious adverse effect of acetaminophen?

alcohol

What clinical finding does a nurse anticipate when admitting a client with an extracellular fluid volume excess?

distended jugular veins

A client reports severe pain 2 days after surgery. After assessing the characteristics of the pain, which initial action should the nurse take next?

obtain vitals

The nurse should monitor for which involuntary physiologic response in a client who is experiencing pain?

perspiring

A nurse prioritizes client care using Maslow's hierarchy of needs. Which situation should the nurse address first according to Maslow's hierarchy?

A client complains of sleeplessness due to pain post-surgery.

A child who reports shortness of breath, wheezing, and coughing is found to have pulmonary edema and is prescribed furosemide. Which nursing interventions would be beneficial to the client? Select all that apply.

- checking the child's weight everyday - calculating the dose of drug as carefully as possible - assessing the child regularly to help prevent electrolyte loss

What is a nurse's responsibility when administering prescribed opioid analgesics? Select all that apply.

- count the client's respirations - document the intensity of the client's pain - verify the number of doses in the locked cabinet before administering the prescribed dose

What clinical indicators should the nurse expect a client with hyperkalemia to exhibit? Select all that apply.

- diarrhea - weakness - dysrhythmias

The nurse is caring for a client admitted with fluid overload. Which tasks are most appropriate to be delegated to the patient care associate? Select all that apply.

- documenting vital signs - documenting urine output - repositioning the client every one or two hours

A nurse is aware that an older adult is at risk for social isolation as a result of which factors? Select all that apply.

- experiencing progressive macular degeneration - living alone since a spouse's death 3 years ago

The nurse is communicating with an older adult who has a hearing disability. Which intervention by the nurse is beneficial to promote communication? Select all that apply.

- giving the client a chance to speak - making sure that the client knows you are speaking - keeping the communication concise

Which gerontologic assessment findings of the auditory system are related to the inner ear? Select all that apply.

- hair cell degeneration - reduced blood supply to the cochlea - less effective vestibular apparatus in the semicircular canals

While assessing an older adult with decreased perception of touch, the nurse provides instructions to the client to reduce the risk associated with falling. Which statements made by the nurse are beneficial to the client? Select all that apply.

- look where your feet are placed while walking - wear shoes that give good support - if you are unable to change your positions frequently request assistance

A client who underwent surgery feels pain in the lower abdomen. The nurse provides pain relief but the client is still reporting pain. Which actions of the nurse would help the client to get relief? Select all that apply.

- looking for different distraction technique - involving the client's family in creating a new plan for pain relief

What are the desired outcomes that the nurse expects when administering a nonsteroidal antiinflammatory drug (NSAID)? Select all that apply.

- pain relief - antipyresis - reduced inflammation

A client receiving morphine is being monitored by the nurse for signs and symptoms of overdose. Which clinical findings support a conclusion of overdose? Select all that apply.

- slow respirations - bradycardia - sedation

A client has received instructions to take 650 mg aspirin every 6 hours as needed for arthritic pain. What should the nurse include in the client's medication teaching? Select all that apply.

- take the aspirin with meals or a snake - do not chew enteric coated tablets - report persistent abdominal pain

A client with a history of severe diarrhea for the past 3 days is admitted for dehydration. The nurse anticipates that which intravenous (IV) solution will be prescribed initially?

0.9% sodium chloride

The nurse assesses a client's eyes and notices that the pupils are unequal in size and constricted. What condition would be found in the client's medical record?

Anisocoria

How can a nurse minimize agitation in a disturbed client?

By limiting unnecessary interactions with the client

During an annual physical assessment a client reports not being able to smell coffee and most foods. Which cranial nerve function should the nurse assess?

I

A pregnant client's history reveals opioid abuse. What is the nurse's initial plan for providing pain relief measures during labor?

Scheduling pain medication at regular intervals

A client with a known history of opioid addiction is treated for multiple stab wounds to the abdomen. After surgical repair the nurse notes that the client's pain is not relieved by the prescribed morphine injections. The nurse realizes that the failure to achieve pain relief indicates that the client is probably experiencing what phenomenon?

tolerance

A nurse is evaluating a client's response to fluid replacement therapy. Which clinical finding indicates successful replacement?

urinary output of 30 ml in an hour

Which condition will the nurse monitor for in a client with interruption of venous return?

varicosity

Which description is associated with a hematoma?

The visible swelling due to extravasation of blood of sufficient size

During an assessment, the client complains of tenderness when the nurse palpates the calf muscle. What would be the nurse's next assessment?

To evaluate for swelling, warmth and muscle firmness

A nurse is assessing a client who underwent abdominal surgery 10 days ago. The client complains of pain in the abdomen. What type of pain does the client experience?

Visceral pain

A client has been admitted with a diagnosis of intractable vomiting and can only tolerate sips of water. The initial blood work shows a sodium level of 122 mEq/L (122 mmol/L) and a potassium level of 3.6 mEq/L (3.6 mmol/L). Based on the lab results and symptoms, what is the client experiencing?

hyponatremia

A client reports vomiting and diarrhea for 3 days. Which clinical indicator is most commonly used to determine whether the client has a fluid deficit?

loss of body weight

When monitoring fluids and electrolytes, the nurse recalls that the major cation-regulating intracellular osmolarity is what?

potassium