Fundamentals Test 2 Questions (I got wrong)

A nurse is planning care for a group of clients who are receiving oxygen therapy. Which of the following clients should the nurse plan to see first? A- A client who has heart failure and is receiving 100% oxygen via a partial rebreather mask. B- A client who has emphysema and is receiving oxygen at 3L/min via a transtracheal oxygen cannula. C- A client who has an old tracheostomy and is receiving 40% humidified oxygen via tracheostomy collar. D- A client who has COPD and is receiving oxygen at 2L/min via nasal cannula.

A- A client who has heart failure and is receiving 100% oxygen via a partial

A nurse is preparing to assist with ambulation of an older adult client who was on bed rest for 3 days. Which of the following actions should the nurse take to decrease the risk of a fall? A- Use a gait belt during ambulation. B- Ensure the client is wearing socks before ambulating. C- Instruct the client to sit on the edge of the bed for 15 seconds before ambulating. D- Walk 2 feet behind the client during ambulation.

A- Use a gait belt during ambulation.

A nurse is planning to administer pain medication to a client who has pain following abdominal surgery. Which of the following actions should the nurse take first? A- Use the pain scale to determine the client's pain level. B- Discuss the adverse effects of pain medication with the client. C- Obtain the client's vital signs. D- Check the client's allergies.

A- Use the pain scale to determine the client's pain level.

A nurse is teaching a client who is recovering from gallbladder surgery how to use an incentive spirometer. Which of the following information should the nurse include in the teaching? A- Exhale slowly to reach goal volume. B- Hold breath for 5 seconds after goal volume is reached. C- Continue to deep breathe between each cycle. D- Limit repeat pattern of breathing to 5 breaths.

B- Hold the breath for 5 seconds after goal volume is reached.

A nurse is changing the dressings for a client who has two Penrose drains near an abdominal incision. Which of the following adhering devices is the best choice for the nurse to use to decrease skin irritation? A- Abdominal binder B- Montgomery straps C- Hypoallergenic tape D- Plastic tape

B- Montgomery straps

A nurse is preparing to administer an intramuscular injection to a client who is overweight. Which of the following sites should the nurse select for the injection? A- The lower, medial quadrant of the buttock near the coccyx. B- The side hip between the iliac crest and anterior iliac spine. C- The tissue of the posterior upper arm. D- The lower, inner thigh 4 finger widths above the patella.

B- The side hip between the iliac crest and anterior iliac spine.

A nurse is preparing to insert an indwelling urinary catheter for a male client. Which of the following locations should the nurse secure the urinary catheter tubing? A- lateral thigh B- lower abdomen C- mid-abdominal region D- medial thigh

B- lower abdomen

A nurse is preparing eye irrigation for a client who was exposed to smoke and ash. Which of the following actions should the nurse take? A- Hold the irrigator 1.25cm (0.5in) above the eye. B- Direct the irrigation solution upward toward the upper eyelid. C- Exert pressure on the bony prominences when holding the eyelids open. D- Direct the irrigation from the outer canthus to the inner canthus of the eye.

C- Exert pressure on the bony prominences when holding the eyelids open.

A nurse is preparing to remove an NG tube for a client who had a partial colectomy. Which of the following actions should the nurse take? A- Maintain suction while removing the NG tube. B- Instill 100mL of air into the NG tube before removal. C- Pinch the NG tube while removing the tube. D- Instruct the client to breathe in and out during the removal of the NG tube.

C- Pinch the NG tube while removing the tube.

A nurse is caring for a client who is receiving an IV fluid replacement. Which of the following findings should the nurse identify as infiltration of the IV infusion site? A- Redness at the IV catheter entry site. B- A palpable cord is felt along the vein used for the infusion. C- Taut skin around the IV catheter site that is cool to the touch. D- Bleeding at the IV insertion site.

C- Taut skin around the IV catheter site that is cool to the touch.

A nurse is changing the dressings for a client recovering from an appendectomy following a ruptured appendix. The client's srgical would is healing by seconadry intention. Which of the following observations should the nurse report to the provider? A- Tenderness when touched. B- Pink, shiny tissue with a granular appearance. C- Serosanguineous drainage. D- A halo of erythema on the surrounding skin.

D- A halo of erythema on the surrounding skin.

A nurse is collecting a urine specimen for a culture and sensitivity for a client who has a urinary tract infection. The client has an indwelling urinary catheter in place. Which of the following actions should the nurse take? A- Withdraw the specimen from the drainage bag. B- Cleanse the collection port with soap and water. C- Place the specimen in a clean specimen cup. D- Clamp the tubing below the collection port.

D- Clamp the tubing below the collection port.

A nurse is changing the dressings for a client who is 3 days postoperative following a cholecystectomy. The nurse observes yellow, thick drainage on the dressing. The nurse should document this finding as which of the following types of drainage? A- Sanguineous exudate B- Serous exudate C- Serosanguineous exudate D- Purulent exudate

D- Purulent exudate