FUNDAMENTALS Part 2
A nurse is caring for a client who reports not sleeping at night which interferes with her ability to function during the day which of the following interventions should the nurse suggest to this client?
Caffeine is a stimulant the nurse should suggest that the client avoid caffeinated beverages
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?
Explain the procedure to the client it's important to use the most non invasive first before interventions that are invasive
A nurse is teaching a client how to use albuterol metered dose inhaler after removing the cap from the inhaler and shaking the canister what sequence of instructions should the nurse give the client step by step?
Hold the mouthpiece one to two inches in front of your mouth tilt your head back slightly and open your mouth wide depress the canister while taking a slow deep breath hold your breath for 10 seconds
A nurse is measuring a clients vital signs and notices an irregularity in the pulse. Which of the following actions should the nurse take?
If the peripheral pulse is irregular, the nurse should auscultate the apical pulse for 60 seconds to obtain an accurate rate. Then, the nurse should document the irregularity in the clients medical record.
During a physical examination of a client the nurse suspects strabismus which of the following tests should the nurse use to collect additional data?
The corneal light reflex requires the nurse to shine a penlight at the client's eyes and visualize whether the light shines on the same spot bilaterally this test will indicate the alignment of the client's eyes as well as any deviation inward or outward with strabismus the eyes will not align when the client focuses
A nurse is caring for a client who has dysrhythmias which of the following techniques should the nurse use to assess for pulse deficit?
To assess for a pulse deficit the nursing and a second person assesses the clients radial and apical pulses simultaneously and the comparison of both rates to calculate the pulse deficit the nurse should subtract the difference between the apical and radial pulse rates
A nurse in a same day procedure unit is caring for several clients who are undergoing different types of procedures the nurse should anticipate that the client who has which of the following devices can safely undergo magnetic resonance imaging MRI?
A client who has hearing aids can undergo an MRI because the hearing aids can be removed the powerful magnetic field of the MRI could damage the hearing aids so they should be removed prior to a client undergoing MRI
A nurse is preparing to administer a medication to a client which of the following administration schedules should The nurse identify as a prescription to administer the medication once and as soon as possible
A stat medication prescription is carried out immediately or as soon as possible and for one time only
A nurse is preparing to administer oral Fenton and to a client who has seizure disorder before administering medication which of the following actions should the nurse take?
Check the medication dose and the client's identification
A nurse is caring for a client who has a terminal illness. the client asks several questions about the nurse's religious beliefs related to death and dying. Which of the following actions should the nurse take?
Encourage the client to express thoughts about death and dying.
A nurse is providing teaching to an older adult client who has Constipation which of the following statements should the nurse include in the teaching ?
Increased peristalsis occurs after food enters the stomach sitting on the toilet 30 minutes after eating a meal regardless of the feeling the urge to defecate is a recommended method for bowel retaining to treat Constipation
A home health nurse is planning to provide health promotion activities for a group of clients in the community which of the following activities is an example of primary prevention?
Primary prevention includes health education about disease prevention so recommending immunization schedules for adults
A nurse is caring for a client who is dehydrated the nurse should expect that insensible fluid loss of approximately 500 to 600 mill occurs each day throughout which of the following organs?
The skin can excrete approximately 500 to 600 mil of insensible fluid loss this type of fluid loss is continuous and can increase if the client is experiencing a fever or has had a recent burn to the skin
A nurse is preparing to assess the function of a client trigeminal nerve cranial number 5 which of the following items should the nurse gather for the test?
The trigeminal nerve has both sensory and motor capabilities to assess its sensory function the nurse uses a safety pin to assess for recognition of pain and a cotton wisp to evaluate recognition of touch sensations to test motor abilities of cranial nerve #5 the nurse should ask the client to clench the teeth
A nurse is caring for a client who has the head of his head elevated to a 45 degree angle with his knees slightly flexed which of the following positions should the nurse document for the client
This describes fowlers position although various definitions exist for folders position generally a low folders position means 30 degrees of elevation semi folders is 45 to 60 degrees in high folders is 60 degrees to 90 degrees of elevation
A nurse in an emergency department is assessing a client who reports diarrhea and decreased urination for four days which of the following actions should the nurse take to assess the client's skin turgor?
the nurse should Grasp a skin fold on the chest under the clavicle release it and note whether it springs back
A nurse in a providers office is reviewing the laboratory findings of a client who reports chills and aching joints the nurse should identify which of the following findings as an indication of an infection?
A white blood cell count of 15,000 is above the expected reference range and is an indication of an infection
A nurse documents the presence of clubbing of the fingernails for a client who has emphysema which of the following is an underlying cause of this finding ?
Clubbing of the nails of the fingers and toes as a result of chronic hypoxemia low oxygen supplies such as with COPD
A nurse is caring for a client who has terminal cancer the client is proceeding with plans to build a new home the nurse should identify that this behavior typically indicates which of the following stages of grief?
During the denial stage of grief a client is unable to accept the reality of the loss a client who has terminal disease has a limited amount of time so building a house is unrealistic and denies reality
A nurse is caring for an older adult client who has an in the canal hearing aid the client states that the hearing aid is making a whistle sound the nurse should identify which of the following factors is the source for this sound
Factors that can make a hearing aid whistle include a poor seal with the earmold and ear infection or excessive wax in the ear canal an improper fit or a malfunction
A nurse is caring for a client who is 48 hour postoperative following a small bowel resection the client reports gas pains in the periumbilical area the nurse should plan care based on which of the following factors contributing to this post operative complication?
Impaired peristalsis of the intestine normal bowel function is delayed for up to several days following a bowel resection when peristalsis is absent or sluggish intestinal gas builds up producing pain and abdominal distention the nurse should plan to help the client ambulate to promote peristalsis
A nurse is reviewing the correct use of a fire extinguisher with the client which of the following actions should the nurse direct the client to take first?
Remove the safety pin from the extinguisher should be the first action to take when using a fire extinguisher
A nurse enters a client's room and finds a client sitting on the floor and leaning against the side of the bed the client states she slipped while she she was getting out of bed which of the following actions should the nurse take first?
Using the nursing process the nurse should first evaluate the client for any injuries or physiological changes the nurse should also notify the provider to determine the need for any further examination or intervention
A nurse is reviewing measures to prevent back injuries with assistive personnel which of the following instructions should the nurse include
When lifting an object spread your feet apart to provide a wide base of support
After assessing a client's radial pulse the nurse documents radial pulse 4 plus bilaterally the nurse should document this finding when a client's pulse have which of the following qualities?
a pulse of four plus is bounding and does not appear with moderate pressure pull strength ranges from absent zero to bounding 4 plus
A nurse is preparing to administer eye drops to a client following surgery. which of the following actions should the nurse take when instilling the eye drops?
The nurse should drop the eye medication in the lower conjunctive iliac to avoid placing the drops on the cornea and causing damage
A nurse is caring for a client who has cancer and is experiencing pain the nurse should implement which of the following interventions to assist the client with pain relief?
The nurse should encourage the client to use music therapy to reduce anxiety provided distraction and relieve pain
A nurse is removing personal protective equipment PPE after performing a procedure for a client who requires isolation precautions which of the following items of PPE should the nurse remove first
According to evidence based practice the nurse should first remove the gloves because they are the most contaminated piece of PPE next the nurse should remove the goggles or face shield and then the gown finally the nurse should remove the respirator or mask because it is the least contaminated piece of PPE
A nurse is caring for a client who has acute renal failure which of the following assessments provides the most accurate measure of the client's fluid status?
According to evidence based priority setting framework daily weight provides important information about the clients fluid status a gain or loss of 1 kilogram which is 2.2 pounds indicates a gain of or loss of one liter of fluid therefore weighing the client daily will provide the most accurate fluid status measurement
A nurse is beginning her shift on reviewing the medication administration records Mars for her clients she notes a dosage of medication above the safe range and sees that a nurse administered that dosage during the previous shift which of the following actions should the nurse take?
After assessing the client for adverse effects of the medication the nurse should first notify the provider about her observations to determine the next step and to clarify the dosage
A nurse is teaching a newly licensed nurse about pain management in clients age 65 and older which of the following pieces of information should the nurse include in the teaching?
Clients who are age 65 or older or reluctant to report pain the nurse should instruct the newly licensed nurse that clients age 65 and older frequently can be reluctant to report pain because they might not want to bother or anger caregivers and might believe that pain is expected
A nurse is performing a mental status examination on a client who has manifestations of dementia which of the following directions should the nurse give the client when evaluating the clients ability to think abstractly
Discuss the meaning of a common proverb this part of the mental status examination evaluates the client's ability to think abstractly
A nurse is admitting a client who has decreased circulation in his left leg which of the following actions should the take first?
For a client who has decreased circulation in the leg evaluating pidal pulses is critical in order to determine adequate blood supply to the foot
A nurse is caring for a middle aged adult client the nurse should evaluate the client for progress toward which of the following developmental tasks
Middle aged adults usually feel more comfortable with themselves and ceased to make comparisons with others
A nurse is preparing a client who is scheduled for hysterectomy for transport to the operating room the client states she no longer wants to have surgery which of the following actions should the nurse take
Notify the provider of the clients decision while acting as a client advocate the nurse should support her decision and notify the provider
A nurse is using the I-SBAR communication tool to give a client provider information about the client the nurse should convey this client's pain status in which portion of the report
The nurse provides information about assessment findings in this portion of the report including vital signs pain assessment and changes in assessment findings
A nurse is preparing to administer medication to a client who has gout. The nurse discovers that an error was made during the previous shift in which the client received atenolol instead of allopurinol. Which of the following interventions is the nurse's priority?
The first action is to assess the client by measuring the clients apical pulse. Atenolol is a beta blocker and can decrease the clients heart rate.
A nurse on a medical surgical unit is caring for a client who is at risk for experiencing seizures which of the following pieces of equipment must be available at the client's bedside at all times?
The greatest risk to a client who is having a seizure is an injury from aspirating secretions or emesis therefore the nurse must have suction equipment available for clearing the mouth of secretions or emesis to reduce this risk
During the insertion of a urinary catheter for a client the tip of the catheter brushes against the nurses arm which of the following actions should the nurse take
The insertion of a urinary catheter is a sterile procedure the only way to ensure sterility of the catheter the nurse plans to insert is by obtaining a new sterile catheter and following surgical S basis throughout the insertion procedure
A nurse is performing an otoscopic examination of the clients right here the light reflects is visible in the right lower quadrant of the tympanic membrane which of the following actions should the nurse take in response to this finding?
The light of the otoscope reflects off the tympanic membrane which is cone shaped and triangle. in the right ear it is visible in the right lower quadrant of the eardrum in the left ear it is visible in the lower left quadrant. we must document this as an expected finding
A nurse is performing a neurological assessment for a client by asking the client to stick out his tongue which of the following cranial nerves is the nurse testing
The nurse is checking the function of cranial nerve #7 which is the hypoglossal which innervates the tongue by observing a range of tongue movements
A nurse in the emergency department is caring for an inmate who has a laceration and is bleeding the client was brought to the facility by a guard who asks the nurse about the client's HIV infection status which of the following actions should the nurse take
The nurse is not able to supply this information to the guard in order for the guard to obtain this information the client must offer the information freely therefore the nurse should instruct the guard to ask the client for this information
A nurse is admitting a client who is experiencing an exacerbation of heart failure at which of the following times should the nurse initiate discharge planning?
The nurse should initiate discharge planning as soon as the client is admitted to the facility this is intended to ensure the continua T of care and meet the clients carers needs this process should include each member of the client's health care team
a nurse is caring for a client who has a temperature of 38.7C which is 101.7F which of the following action should the nurse take
The nurse should maximize the clients heat loss by keeping the clients clothes and bed linens dry the nurse should also reduce external coverings on the client's bed without causing shivering
A client is preparing to administer a tap water anema to a client which of the following actions should the nurse take?
The nurse should place the client into the left Sims position for the insertion of an anema this left lateral position facilitates the flow of the anema solution into the sigmoid and descending: the anus is exposed by flexing the right leg
A nurse is beginning a therapeutic relationship with the client which of the following actions should the nurse take to convey empathy when using the therapeutic communication technique of active listening?
The nurse should sit with arms and legs uncrossed crossing them suggest a defensive posture so assume an open position
A nurse on the medical surgical unit is caring for a client which of the following action should the nurse prioritize when using the nursing process
The nursing process is based on the scientific process the first step in the scientific process is collecting data therefore the first step in the nursing process is assessing and obtaining information about the client
A nurse is employing a thorough systemic method while obtaining objective data about a client through which of the following methods should the nurse collect this information
Through the physical examination there will be physical findings that are objective and the nurse should collect this information in a systematic way
