PN Fundamentals

A nurse is preparing to collect data bout the function of a client's trigeminal nerve or cranial nerve (CNV). Which of the following items should the nurse gather for the test? 1. sugar 2. coffee 3. cotton wisps 4. snellen chart

Cotton wisps ; trigeminal nerve has sensory and motor capabilities. Use cotton to test sensation, ask client to clench teeth to test motor abilities.

A nurse is collecting data from a term newborn who is 8 hours old. Which of the following reflexes should the nurse identify as a preliminary indications that during gestation, the newborn developed the ability to hear? 1. babinksi 2. tonic neck 3. rooting 4. moro

Moro ; the newborn extends both arms and legs outward and then draws them back inward in response to a loud noise such as a sudden clap. Generally indicates that the newborn heard the noise.

A nurse is caring for a client who has a deficiency in vitamin D. Which of the following foods should the nurse recommend the client include in his diet? 1. whole milk 2. chicken 3. oranges 4. dried peas

Whole milk ; it is often fortified with vitamin D and contains vitamins A and K. Chicken contains many of the B complex vitamins. Oranges are a good source of vitamin C.

A nurse is reinforcing teaching with an older adult client who is healthy and has chronic constipation about establishing a bowel retraining program. Which of the following statements should the nurse include in the teaching? 1. "limit physical activity during the day" 2. "Set a time limit of 10 minutes when attempting to defecate" 3. "Increase the fiber content of your diet" 4. "Increase your fluid intake to 5,000 mL per day"

"Increase the fiber content of your diet" ; also increase exercise with walking, modified sit-ups, and pelvic tilt exercises. Allow 15-20 minutes to defecate. 5,000 mL of fluid is unreasonable.

A nurse is assisting a client who has dysphagia at mealtime. Which of the following actions should the nurse take? 1. assist the client into a semi-sitting position 2. have the client lean slightly backeard 3. advise the client to tuck his chin downward 4. instruct the client to tilt his head slightly backward

Advise the client to tuck his chin downward ; the client should sit upright, lean slightly forward, tilt his head forward, and tuck his chin in.

A nurse is reinforcing teaching with a client who is postop following a knee arthroplasty about the muscles he will need to strengthen in physical therapy. Which of the following muscle groups are responsible for movement at the knee joint? 1. antigravity 2. antagonistic 3. synergistic 4. skeletal

Antagonistic ; the antagonistic group is responsible for the movement of the knee joint by contracting while other muscles relax.

A nurse rates a client's biceps reflex as 2+. Which of the following characteristics should the nurse document about the client's reflexes? 1. diminished 2. average 3. brisk 4. hyperactive

Average ; reflexes range on a scale of 0 to 4+. Active or expected reflexes are 2+.

A nurse is collecting data during a neurological exam. When asking the client to stick out his tongue, which of the following cranial nerves is the nurse testing? 1. CN XII 2. CN X 3. CN VIII 4. CN V

CN XII ; the hypoglossal nerves innervates the tongue. CN X (vagus) = vocalization CN VIII (vestibulocochlear) = Rinne/Weber test ; whisper test CN V (trigeminal) = clench teeth and palpate masseter muscles

A nurse is caring for a client who is immobile. The nurse should recognize that immobility places the client at risk for which of the following health alterations? 1. increased intestinal motility 2. respiratory alkalosis 3. decreased cardiac output 4. hypocalcemia

Decreased cardiac output ; with immobility, the heart rate increases to compensate for increased venous pooling. Hypoventilation will lead to CO2 retention and respiratory acidosis.

A nurse is performing eye irrigation for a client who was exposed to smoke and ash. Which of the following actions should the nurse take? 1. hold the irrigator 1.25 cm (0.5inch) above the eye 2. direct the irrigation solution upward toward the upper eyelid 3. exert pressure on the bony prominences when holding the eyelids open 4. direct the irrigation from the outer canthus to the inner canthus of the eye

Exert pressure on the bony prominences when holding the eyelids open ; hold the client's upper lid against the eyebrow and the lower lid against the cheekbone. Hold the irrigator 1 inch above the eye. Direct the irrigation onto the lower conjunctival sac and from the inner canthus to the outer canthus.

A nurse is collecting data regarding a client's nutritional status during a community health screening. The client is consuming 500 calories per day more than his energy level requires. When will the client have gained 4.5 kg (10lb)? 1. 10 months 2. 5 months 3. 5 weeks 4. 10 weeks

10 weeks ; 1 lb of fat is equivalent to 3,500 calories. 500 calories/day for 7 days = 1 lb gain each week.

A nurse is caring for a client who has a hearing impairment. Which of the following interventions should the nurse use when speaking with the client? 1. speak directly toward the client's impaired ear 2. exaggerate lip movements 3. speak loudly 4. face the client when speaking

Face the client when speaking ; also stand or sit at the same level, and speak toward the client's best ear, enunciate and avoid mumbling. Speaking loudly or shouting can distort sounds.

A nurse is reviewing the medical record of an older adult client. For which of the following medications should the nurse request a hearing assessment for the client? 1. omeprazole 2. ferrous sulfate 3. digoxin 4. furosemide

Furosemide ; it can cause ototoxicity, especially in older adult client due to a decrease in medication metabolism in the kidneys.

A nurse at an ophthalmology clinic is collecting data from a client who was referred by the provider for a potential cataract. Which of the following client reports is consistent with cataracts? 1. halos when looking at lights 2. loss of peripheral vision 3. bright flashes of light and floaters 4. eyestrain and headaches with close work

Halos when looking at lights ; other manifestations of cataracts are difficulty seeing at night, glare sensitivity, and decreased visual acuity even in daylight.

A nurse is caring for a 15 y/o client whose symptoms suggest an STI. The client's parent is unavailable, but the grandmother accompanied the client to the clinic. Which of the following actions should the nurse take? 1. explain that the treatment can wait until the parent is available 2. inform the grandmother that she may give consent for the treatment 3. invoke the principle of implied consent and prepare the client for treatment 4. have the adolescent sign the consent form

Have the adolescent sign the consent for ; unemancipated minors can give informed consent in certain situations such as treatment for STIs or substance use disorders.

A nurse is assisting a provider with performing thoracentesis to remove pleural fluid. How should the nurse position the client? 1. sitting upright and facing forward in bed 2. leaning forward over a pillow 3. lying supine 4. side-lying with the head flexed

Leaning forward over a pillow ; on a pillow and across an over-bed table is optimal for thoracentesis and chest-tube insertion. It widens the posterior intercostal spaces and makes it easier to access and drian pleural fluid.

A nurse is using the Braden scale to predict the pressure-ulcer risk for a client in a long-term care facility. Using this scale, which of the following parameters should the nurse evaluate? 1. incontinence 2. mental state 3. nutrition 4. general physical condition

Nutrition ; nutrition, sensory perception, moisture, activity, mobility, and friction and shear are the parameters of the Braden scale for determining a client's risk for developing pressure ulcers. Incontinence, mental state, and general physical condition are parameters on the Norton scale.

A nurse in a provider's office is measuring an adult client and notes a decrease in height from the previous year. The nurse should identify this findings as a manifestation of which of the following musculoskeletal system disorders? 1. osteoporosis 2. scoliosis 3. kyphosis 4. lordosis

Osteoporosis ; loss of height is often an indication of osteoporosis. This occurs due to loss of calcium in the vertebrae, which can allow them to fracture and collapse.

A nurse is caring for an older adult client who has a hip fracture and is rating his pain 8/10. Which of the following medications should the nurse administer? 1. capsaicin topical gel 2. oxycodone/acetaminophen 3. celecoxib 4. aspirin

Oxycodone/acetaminophen ; this is a combination of an opioid and nonopioid analgesic for severe pain. Monitor for adverse effects such as respiratory depression.

A nurse is performing a physical exam of a client. To evaluate the client's skin moisture, the nurse should use which of the following techniques? 1. percussion 2. auscultation 3. inspection 4. palpation

Palpation ; feel texture, temperature, masses, or moisture.

A nurse is preparing to administer a tap water enema to a client. Which of the following actions should the nurse take? 1. raise the enema bag if the client experiences cramping 2. lubricate 2.54 cm (1 in) of the tip of the rectal tube prior to insertion 3. place the client in a left Sims' position 4. don sterile gloves prior to the procedure

Place the client in a left Sims' position ; administer fluids slowly and lower the container when there if fullness or pain during administration. Lubricate 5.08 cm (2 in) of the rectal tube. Clean gloves are necessary.

A nurse is caring for a client who has xerostomia with a lack of saliva. The nurse should identify that which of the following nutrients will be affected by the lack of salivary amylase? 1. fat 2. protein 3. starch 4. fiber

Starch ; majority of starch breakdown occurs in the small intestine with pancreatic amylase. Lipase breaks down fats. Pepsin breaks down proteins.

As part of a neurological exam, a nurse instructs a client to keep his eyes closed, places an object in his hand, and asks him to identify the object. Which of the following abilities is the nurse evaluating with this technique? 1. gustation 2. stereognosis 3. proprioception 4. kinesthesia

Stereognosis ; this is the ability to identify an object's size, shape, and texture via tactile sensation. Gustation is the ability to taste.

A nurse is collecting data about a client's respiratory system. Which of the following breath sounds should the nurse expect to hear over the periphery of the major lung fields? 1. vesicular 2. bronchial 3. rhonchi 4. bronchovesicular

Vesicular ; these sounds are soft and low-pitched. Bronchial sounds are high-pitched, hollow, and loud and are heard over the trachea.

Which of the following statements about the role of folic acid should the nurse provide? 1. "Clients who are postmenopausal need to limit their intake of folic acid to reduce the risk of stroke" 2. "Dietary folic acid is not really important after the childbearing years" 3. "Healthy clients who are postmenopausal require a daily folic acid supplement" 4. "Adequate folic acid intake is associated with a reduced risk of heart disease"

"Adequate folic acid intake is associated with a reduced risk of heart disease" ; shows significantly lower levels of homocysteine (risk factor for heart disease). Increase daily dietary intake of foods such as orange juice, beans, legumes, and green leafy vegetables, as well as foods enriched with folic acid such as breads and pastas.

The client asks how transcutaneous electrical nerve stimulation (TENS) helps pain management. Which of the following responses should the nurse make? 1. "It provides a distraction from the pain" 2. "It modulates the transmission of the pain impulse" 3. "It promotes increased circulation to the painful area" 4. "It elicits a relaxation response"

"It modulates the transmission of the pain impulse" ; it applies low-voltage electrical stimulation directly over a location of pain at an acupressure point.

A nurse is beginning her shift and reviewing the MAR for her clients. She notes a medication dosage above the safe range and sees that another nurse administered that dosage during the previous shift. Which of the following actions should the nurse take? 1. call the nurse to verify that the client received that dosage 2. administer the medication in a safe dosage 3. give the dose the provider prescribed 4. call the provider to clarify the dosage

Call the provider to clarify the dosage ; after check the client for adverse effects, notify the provider of your observations to determine the next action.

A nurse in a provider's office is collecting data from a 3 y/o client during a routine physical. Which of the following findings should the nurse report to the provider? 1. can skip 2. can identify 4 colors 3. cannot print their name 4. cannot walk-up stairs independently

Cannot walk-up stairs independently ; 3 y/o toddlers should be able to walk up steps, use blocks to build a bridge, balance on a foot, jump, copy a circle, and speak in sentences of 3-4 words.

A nurse is caring for a client who requires a dressing change. Which of the following actions should the nurse take? 1. clean the incision from bottom to top 2. apply sterile gloves prior to opening the dressing packages 3. remove the tape by pulling away from the wound 4. clean the drain site from the center outward

Clean the drain site from the center outward ; prevents introducing microorganisms from the periphery of the wound into the center of the wound. Clean the incision from top to bottom - the top of the incision is cleaner. Apply sterile gloves after opening dressing packages. Pull the tape toward the wound to avoid creating strain on the wound and its sutures.

A nurse is collecting data about a client's pulses. Which of the following descriptions should the nurse use to document the findings? 1. peripheral pulses equal bilaterally at a rate of 60/min 2. radial, brachial, and pedal pulses bilaterally weak 3. peripheral pulses bilaterally symmetric, equal, and strong in all 4 extremities 4. brachial, radial, popliteal, and dorsalis pedis pulses regular, 58, and bilaterally palpable

Peripheral pulses bilaterally symmetric, equal, and strong in all 4 extremities ; documentation of peripheral pulse evaluation should include strength, equality, and symmetry in all 4 extremities. HR is not a component of peripheral pulse evaluation.

A nurse at a long-term care facility notes that a client with dementia is having problems with orientation. Which of the following actions should the nurse take to improve the client's level of orientation? 1. encourage the client to make choices about meals and activities 2. use written signs to label specific rooms 3. post a large calendar on the bulletin board 4. place a wander alert electronic alarm bracelet on the client's wrist

Post a large calendar on the bulletin board

A nurse is caring for a client who has aphasia following a stroke. Which of the following actions should the nurse take? 1. present a single idea in a sentence 2. avoid using nonverbal communication techniques 3. speak loudly 4. use simplified language

Present a single idea in a sentence ; aphasia is the loss of ability to understand or express speech. Also allow time for the client to process and respond to the nurse. Use nonverbal gestures, speak slowly and clearly, avoid using childish tones.

A nurse is planning to administer diphenhydramine hydrochloride to an older adults client. Which of the following actions should the nurse take prior to administration? 1. review the client's medical record for a history of glaucoma 2. plan to administer medication 30 minutes before a meal 3. explain that he will need to restrict his fluid intake 4. remind the client that his appetite might increase when starting the medications

Review the client's medical record for a history of glaucoma ; diphenhydramine is contraindicated for clients who have narrow-angle glaucoma. The client should increase fluid intake. Anorexia, nausea, and vomiting are GI adverse effects of this medication.

A nurse is reinforcing teaching with an older adult client who has constipation. Which of the following statements should the nurse include in the teaching? 1. Drink minimum 1L of fluid daily 2. increase your intake of refined-fiber foods 3. sit on the toilet 30 minutes after eating a meal 4. take a laxative every day to maintain regularity

Sit on the toilet 30 min after eating a meal ; increased peristalsis occurs after food enters the stomach. This is a recommended method of bowel retraining to treat constipation. Consume at least 1.5L of fluid. Increase consumption of coarse fiber and whole grains.

A nurse is examining a client for signs of costovertebral angle tenderness. The nurse should place the client in which of the following positions for evaluation? 1. sims' 2. supine 3. sitting 4. standing

Sitting ; the costovertebral angle is the area where the spine and twelfth rib intersect. A sitting position promotes relaxation and allows access to the back for percussion.

A nurse is caring for a client who has peripheral edema. The nurse should identify that which of the following nutrients regulates extracellular fluid volume? 1. sodium 2. calcium 3. potassium 4. magnesium

Sodium ; regulates extracellular fluid balance as well as nerve impulse transmission, acid-base balance.