Nursing I: Fundamentals 2 Practice Test

A nurse is caring for a client who has just had a mastectomy and has a closed wound suction device (hemovac) in place. Which nursing action will ensure proper operation of the device?

Collapsing the device whenever its 1/2-2/3 full of air.

A client is admitted for evaluation and control of HTN. Several hours after the client's admission, the nurse discovers the client supine on the floor, unresponsive to verbal or painful stimuli. The nurse's first reaction at this time is to:

Establish an airway

When communicating with a client who is hearing impaired, the nurse should

Face the client and speak slowly

While changing the linen on the client's bed, the nurse should

Hold the linen away from his body and clothing.

Which nursing action prevents injury to a client's eye during the administration of eye drops

Holding the tip of the container above the conjunctival sac

A client returning from the surgical suite following a vaginal hysterectomy is awake and asking for something to drink. Her post-op diet prescription reads: " clear liquids, advance diet as tolerated." Which of the following is appropriate for the nurse to tell the patient?

I am going to listen to your abdomen

A client's provider has ordered that sputum specimen be collected for culture and sensitivity. The nurse plans to collect this specimen...

In the morning upon rising.

The mother of a toddler calls the nurse "Help! My baby is choking on his food!" The nurse determines that the heimlich maneuver is necessary based on which finding:

Inability of the toddler to cry or speak

A nurse is caring for a client who has a new prescription for tube feeding. The nurse understands that the provider prescribed tube feeding because the client:

Is unable to swallow foods by mouth

A nurse has inserted an indwelling catheter for a male patient. Where should the nurse tape the catheter to prevent pressure on the client's urethra at the penoscrotal junction?

Lower abdomen

When a nurse makes an initial assessment of a client who is post-op following gastric resection, the client's NG tube is not draining. The nurse's attempt to irrigate the tube with 10ml 0.9% NaCl was unsuccessful, so she determines that the tube was obstructed. Which of the following actions should the nurse take?

Notify the surgeon.

A client develops a fecal impaction. Before digital removal of the mass, which type of enema should the nurse give to loosen the feces?

Oil Retention

A nurse is caring for a client who is 3 days post-op following a cholecystectomy. The nurse suspects a wound infection because the drainage on the dressing is yellow and thick. The nurse identifies this type of drainage as:

Purulent

CPR has been initiated for the client in the ER. The nurse understands that a critical concept related to effective cardiac chest compressions is the need to:

Push hard and deep on the chest

A nurse is performing an eye irrigation for the client who has been exposed to smoke and ash. Which of the following nursing actions should receive the highest priority during the irrigation?

Wearing gloves during the procedure.

The nurse is caring for an adult who has fluid volume excess. When weighing the client, the nurse should

Weight the client upon rising.

A nurse is caring for several clients who are receiving O2 therapy. Which client should the nurse assess most frequently for manifestations of oxygen toxicity?

100% oxygen via partial rebreathing mask

A client is recovering fromg allbladder surgery performed under general anesthesia. The nurse should encourage the client to use the incentive spirometer how many times per hour?

4-5 times per hour

A client is recovering from an appendectomy for a ruptured appendix has a surgical wound healing by secondary intention. When changing the client's dressing, which observation should the nurse report to the client's surgeon?

A halo of erythemia on the surrounding skin

A nurse is in a public building when someone cries out "Help! I think he is having a heart attack!" The nurse responds to the scene and finds the unconcious adult lying on the floor. Another bystander has obtained an AED. The nurse's first action, after making certain someone has called for EMS, should be to

Administer cardiac compressions.

A nurse is assisting a client with a meal. The client suddenly grabs at her neck with both hands and appears frightened. The appropriate nursing action is to

Ask if the patient is choking

In planning care for a client with surgical wound helating by secondary intention, the nurse can anticipate that the client will

Be at an increased susceptibility for infection.

A nurse is caring for a client who is incontinent of loose stool and is reporting a painful perineum. Which of the following is the priority nursing action?

Check the client's perineum

A post-op nurse has an indwelling catheter in place to gravity drainage. The nurse notes that the client's urine bag has been empty for 2 hours. The first action the nurse shoudl take is to:

Check to see if the tubing was kinked.

When obtaining a urine specimen for a culture and sensitivity from an indwelling catheter, the nurse should:

Cleanse the entry port priot to withdrawing urine.

A nurse is collecting a urine specimen for a client to test via urine dipstick the urine's specific gravity. The nurse knows the result will indicate the amount of:

Solutes in the urine

A nurse is assessing a client admitted with sudden onset of severe back pain of unknow origin. Which statement would be most effective for the nurse to use to elicit further information from this client about his pain?

Tell me how you are feeling right now.

A nurse is caring for a client who is receiving an IV that has infiltrated. Which of the following would be an unexpected finding when the nurse assesses the client's infusion line and insertion site?

The area around the injection site feels warm when touched.

When ambulating a frail, older adult client, the nurse should

Use the transfer belt if the client is unsteady

A client is hospitalized for an infection of a surgical wound following abd surgery. To promote healing and fight wound infection the nurse plans to arrange to increase the client's intake of:

Vitamin C and Zinc

A nurse is planning to collect a liquid stool specimen from a client for ova and parasites. Inaccurate test results may result if the nurse:

Refrigerates the collected specimen

A client being discharged following abdominal surgery will be performing his own dressing changes at home. It is most important for the nurse to include which of the following in the discharge plan?

Demonstration of appropriate hand hygeine

When replacing a client's surgical dressing, the nurse should:

Don clean gloves to remove the old dressing

An older adult client has been hospitalized on bed rest for 1 week. The client reports elbow pain. Which of the following is an appropriate initial action for the nurse caring for this client to take

Examine the elbow

A nurse is preparing to instert a NG tube for a client admitted with bowel obstruction. Which of the following should the nurse do first?

Explain the procedure to the client.

A client who is post-op following laparotomy is reporting pain and dry mouth. The client has morphine sulfate ordered to control the pain. Before administrering the morphine sulfate prescribed for the client the nurse should first

Measure the client's vital signs.

A client returns from surgery with two penrose drains in place. Anticipating frequent dressing changes, what should the nurse use around the incision site?

Montgomery straps

A nurse takes an older adult lient who has dysphagia following a CVA to the dining room for dinner. When assisting the client at mealtime, the nurse should:

Offer the client tart or sour foods. (This makes it easier for them to swallow)

A nurse is teaching a lient with a new colostomy about how to irrigate the ostomy. The nurse realizes that the client needs further teaching when the client

Positions the irrigating solution bag 30 inchees above the stoma

A nurse is caring for a client who is post-op following a partial colectomy. THe patient has a NG tube set on low continuous suction. The client tells his nurse that his throat is sore and asks the nurse when the NG tube will be taken out. Which of the following responses by the nurse is appropriate at this time?

When the GI tract is working again, in about three to five days, the tube can be removed.