RN Fundamentals Online Practice 2023A

A nurse is caring for a client who has an indwelling urinary catheter. Which of the following findings indicates that the catheter requires irrigation? Urine has an unusual odor Urine specific gravity is 1.035 Bladder scan shows 525 mL of urine Urine is positive for ketones

Bladder scan shows 525 mL of urine A client who has an indwelling urinary catheter should have a continuous urine flow without an accumulation of urine in the bladder; therefore, the nurse should irrigate the catheter to resolve any existing blockage. Urine is positive for ketones is a sign of diabetes mellitus with poor glucose control; however, it is not an indication for irrigation

A nurse is admitting a new client. Which of the following actions should the nurse take while performing medication reconciliation? Verify the client's name on their identification bracelet with the medication administration record Call the pharmacy to determine whether the client's medications are available Compare the client's home medications with the provider's prescriptions Place the client's home medication bottles in a secure location

Compare the client's home medications with the provider's prescriptions

A nurse is administering 1L of 0.9% sodium chloride to a client who is postoperative and has fluid volume deficit. Which of the following changes should the nurse identify as an indication that the treatment was successful? Increase in hematocrit Increase in respiratory rate Decrease in HR Decrease in capillary refill time

Decrease in HR

A nurse is assessing a client who received an IV fluid bolus for dehydration. Which of the following findings should the nurse identify as an indication of fluid volume excess? Hypotension Weak, thready pulse Slow capillary refill Distended neck veins

Distended neck veins

A client who is nonambulatory notifies the nurse that their trash can is on fire. After the nurse confirms the presence of the fire, which of the following actions should the nurse take next? Activate the emergency fire alarm Extinguish the fire Evacuate the client Confine the fire

Evacuate the client

A nurse is preparing to apply a dressing for a client who has a stage 2 pressure injury. Which of the following types of dressing should the nurse use? Alginate Gauze Transparent Hydrocolloid

Hydrocolloid - creates a moist wound bed Alginate: stage 3 and 4 to absorb drainage. Alginate forms a soft gel when it comes in contact with drainage Moistened gauze promotes healing in stage 4 or unstageable pressure injuries by causing debridement and allowing granulation of the wound bed. Transparent: promote healing stage 1 by preventing further friction and shearing

A nurse is evaluating teaching for a client who has heart failure. Which of the following 3 statements by the client indicates an understanding of the teaching? SATA I have been weighing myself every other morning I am trying to decrease my intake of foods with potassium I am limiting my sodium intake to 2 grams daily I am eating fewer potato chips and more fruit for snacks I lie down and rest after meals I know to call my doctor if I gain 3 pounds or more in 2 days

I am limiting my sodium intake to 2 grams daily I am eating fewer potato chips and more fruit for snacks I know to call my doctor if I gain 3 pounds or more in 2 days

A nurse is caring for a client who is postoperative and is exhibiting signs of hemorrhagic shock. The nurse notifies the surgeon, who tell the nurse to continue the client's vital signs every 15 min and to report back in 1 hr. Which of the following actions should the nurse take next? Document the provider's statement in medical record Complete an incident report Consult the facility's risk manager Notify the nurse manager

Notify the nurse manager

A middle adult client tells the nurse, "I feel so useless now that my children do not need me anymore." Which of the following responses should the nurse make? Most people are happy when their children grow up and leave home You should be proud that your children are becoming independent Maybe you should consider why are you feeling useless People in middle adulthood often find satisfaction in nurturing and guiding young people

People in middle adulthood often find satisfaction in nurturing and guiding young people

A nurse is caring for a client who has tuberculosis. Which of the following actions should the nurse take? SATA Place a client in the room with negative pressure airflow Wear gloves when assisting the client with oral care Limit each visitor two 2 hr increments Wear surgical mask when providing client care Use antimicrobial sanitizer for hand hygiene

Place a client in the room with negative pressure airflow Wear gloves when assisting the client with oral care Use antimicrobial sanitizer for hand hygiene

A nurse is reviewing a client's fluid and electrolyte status. Which of the following findings should the nurse report to the provider? BUN 15 mg/dL Creatinine 0.8 mg/dL Sodium 143 mEq/L Potassium 5.4 mEq/L

Potassium 5.4 mEq/L BUN 10-20 mg/dL Cr 0.5-1.3 mg/dL Sodium 136-145 mEq/L Potassium 3.5-5 mEq/L

A nurse is completing an admission assessment for a client who reports vomiting and diarrhea for the past 3 days. Which of the following findings should the nurse expect? Neck vein distension Urine specific gravity 1.010 Rapid HR BP 144/82 mm Hg

Rapid HR Tachycardia indicates fluid volume deficit, an expected finding for a client who has had vomiting and diarrhea for 3 days.

A nurse is talking with the partner of a client who has dementia. The client's partner's expresses frustration about finding time to manage household responsibilities while caring for their partner. The nurse should identify that the partner is experiencing which of the following types of role-performance stress? Role ambiguity Sick role Role overload Role conflict

Role overload

A nurse is lifting a bedside cabinet to move it closer to a client who is sitting in a chair. To prevent self-injury, which of the following actions should the nurse take when lifting this object? Bend at the waist Stand close to the cabinet when lifting Use the back muscles for lifting Keep the feet close together

Stand close to the cabinet when lifting

A nurse is caring for a client who has a NG tube and is receiving intermittent through an open system. Which of the following actions should the nurse take first? Rinse the feeding bag with water between feedings Tell the client to keep the HOB elevated at least 30 degree Make sure the enteral formula is at room temperature Wipe the top of the formula can with alcohol

Tell the client to keep the HOB elevated at least 30 degree

A nurse is caring for a client who has a sodium level of 125 mEq/L. Which of the following findings should the nurse expect? Numbness of the extremities Bradycardia Positive Chvostek's sign Abdominal cramping

Abdominal cramping Normal range Na+: 135-145 mEq/L Hyponatremia - abdominal cramping, weakness, confusion, lethargy, headache, and nausea Tachycardia is manifestation of hyponatremia along with hypovolemia.

A nurse is admitting a client who has rubella. Which of the following types of transmission-based precautions should the nurse initiate? Droplet Airborne Contact Protective environment

Droplet

A nurse is caring for a client who has diarrhea due to shigella. Which of the following precautions should the nurse implement for this client? Have the client wear a mask when receiving visitors Wear a gown when caring for a client Assign a client to a room with negative-pressure airflow exchange Limit a client's time with visitors to more than 30 min per day

Wear a gown when caring for a client

A nurse is caring for a client who is postoperative. When the nurse prepares to change the client's dressing, they say, "Every time you change my bandage, it hurts so much." Which of the following interventions is the nurse's priority action? Encourage the client to relax and take deep breathes during the dressing change Educate the client about the importance of the dressing change to prevent infection Assist the client to a comfortable position for the dressing change Administer pain medicatio

Administer pain medication 45 min before changing the client's dressing

A nurse is planning care of an adolescent who is postoperative following a lumbar laminectomy. Which of the following interventions should the nurse include in the plan of care? Limit the adolescent's visitors Select the food choices for the adolescent Allow the adolescent to make decisions reagarding their daily routine Encourage the adolescent's guardian to assist with personal hygiene

Allow the adolescent to make decisions reagarding their daily routine

A nurse is preparing to delegate client care tasks to AP. Which of the following tasks should the nurse delegate? Ambulating a client who is postoperative Inserting an indwelling urinary catheter for a client Demonstrating the use of an incentive spirometer to a client Confirming that a client's pain has decreased after receiving an analgesic

Ambulating a client who is postoperative

A nurse has just inserted a NG tube for a client. Which of the following findings should the nurse expect to confirm correct tube placement? The tube aspirate has a pH of 7 An X-ray shows the end of the tube above the pylorus Bowel sounds are present on auscultation The client reports relief of nausea

An X-ray shows the end of the tube above the pylorus Gastric aspirate from a client who has been fasting for several hours should have a pH of 4.0 or less. Intestinal fluid or fluid from the client's airway usually has a pH higher than 6.0.

A nurse is planning care for a client who has vision loss. Which of the following interventions should the nurse include in the plan of care to assist the client with feeding? Assign a staff member to feed the client Provide small-handled utensils for the client Thicken liquids on the client's tray Arrange food in a consistent pattern on the client's plate

Arrange food in a consistent pattern on the client's plate

A nurse is caring for a client who is having difficulty breathing. The client is supine and is receiving supplemental oxygen via a nasal cannula. Which of the following interventions should the nurse take first? Suction the client's airway Instruct the client to perform incentive spirometry every hour Humidify the client's supplemental oxygen Assist the client to an upright position

Assist the client to an upright position => assists with chest expansion and increases the effectiveness of the existing supplemental oxygen. HOB to semi-Fowler's or high-Fowler's position to facilitate maximal chest expansion. Sitting upright improves gas exchange and prevents pressure on the diaphragm from abdominal organs. Humidify with supplemental oxygen can help to thin secretions that can limit airflow.

A nurse is planning care for a client who has had a stroke, resulting in aphasia and dysphasia. Which of the following tasks should the nurse assign to an assistive personnel (AP)? SATA Assist the client with a partial bed bath Measure the client's BP after the nurse administers an antihypertensive medication Test the client's swallowing ability by providing thickened liquids Use a communication board to ask what the client wants for lunch Irrigate the client's indwelling urinary catheter

Assist the client with a partial bed bath Measure the client's BP after the nurse administers an antihypertensive medication Use a communication board to ask what the client wants for lunch Indwelling urinary catheter is an invasive procedure and is not within the AP's range of function.

A nurse enters a client's room and finds them on the floor. The client's roommate reports that the client was trying to get out of bed and fell over the side rail onto the floor. Which of the following statements should the nurse document about this incident? Incident report completed Client climbed over the sided rails Client found lying on floor Client was trying to get out of bed

Client found lying on floor

A nurse is admitting a client who has an abdominal wound with a large amount of purulent drainage. Which of the following types of transmission precautions should the nurse initiate? Protective environment Airborne precautions Droplet precautions Contact precautions

Contact precautions Major wound infections require contact precautions, which means the nurse should admit the client to a private room. All caregivers should wear a gown and gloves during direct contact with this client Clients who have a compromised immune system require a protective environment Airborne precautions are a requirement for a client who have infections that spread via droplet nuclei that are larger than 5 microns in diameter: tuberculosis and measles Droplet precautions are a requirement for a client who have infections that spread via droplet nuclei that are larger than 5 microns in diameter: rubella, meningococcal pneumonia, streptococcal pharyngitis

A nurse is admitting a client who is having an exacerbation of heart failure. In planning this client's care, when should the nurse initiate discharge planning? During the admission process As soon as the client's condition is stable During the initial team conference After consulting with the client's family

During the admission process => should begin to assess the client's needs and plan for care both during and after the client's time in the facility The initiation of discharge planning does not depend on the client's physiological stability The nurse should only consult with the client's family if the client gives the nurse permission to share that information. In case of a client who has an exacerbation of heart failure, delaying discharge planning until this time could result in overlooking essential care needs

A nurse is assessing four adult clients. Which of the following physical assessment techniques should the nurse use? Use the Face, Legs, Activity, Cry, and Consolability (FLACC) pain rating scale for a client who is experiencing pain Ensure the bladder of the BP cuff surrounds 80% of the client's arm Obtain an apical HR by auscutating at the third intercostal space left of the sternum Palpate the client's abdomen before auscultating bowel sounds

Ensure the bladder of the BP cuff surrounds 80% of the client's arm

A charge nurse is discussing the responsibility of nurses caring for clients who have C.diff infection. Which of the following should the nurse include in the teaching? Assign the client to a room with a negative airflow system Use alcohol-based hand sanitizer when leaving the client's room Clean contaminated surfaces in the client's room with a phenol solution Have family members wear a gown and gloves when visiting

Have family members wear a gown and gloves when visiting

A nurse is caring for a client who has limited mobility in their lower extremities. Which of the following actions should the nurse take to prevent skin breakdown? Place the client in high Fowler's position Have the client use a trapeze bar when changing position Massage areas of skin that are darker than the surrounding skin tissue with unscented lotion Increase the client's intake of carbs

Have the client use a trapeze bar when changing position

A nurse is assessing a client's readiness to learn about insulin self-administration. Which of the following statements should the nurse identify as an indication that the client is ready to learn? I can concentrate best in the morning It is difficult to read the instructions because my glasses are at home I'm wondering why I need to learn this You will have to talk to my partner about this

I can concentrate best in the morning

A nurse is discussing the use of herbal supplements for health promotion with a client. Which of the following client statements indicates an understanding of herbal supplement use? I can take echinacea to improve my immune system I can take feverfew to reduce my level of anxiety I can take ginger to improve my memory I can take ginkgo biloba to relieve nausea

I can take echinacea to improve my immune system => promote immunity and reduce the risk of infection Ginkgo biloba is taken to improve memory and reduce stress. Ginger can be taken to relieve nausea and vomiting and aid in digestion.

A nurse is caring for a client who requires a 24 hr urine collection. Which of the following statements by the client indicates an understanding of the teaching? I had a bowel movement, but I was able to save the urine I have a specimen in the bathroom from about 30 minutes ago I flushed what I urinated at 7:00 am, and have saved all urine since I drink a lot, so I will fill up the bottle and complete the test quickly

I flushed what I urinated at 7:00 am, and have saved all urine since

A nurse is caring for a client with a diagnosis of terminal cancer. Which of the following statements by the client should indicate to the nurse that the client is ready to hear information regarding palliative care? I am ready to learn about chemotherapy to help cure my cancer I just want you to give me something to get this over with soon I know that many people have recovered fully from cancer, so will I I want you to tell me about measures available to keep me comfortable

I want you to tell me about measures available to keep me comfortable

A nurse is caring for a client who is receiving pain medication through. a PCA pump. Which of the following actions should the nurse take? Instruct the family to refrain from pushing the button for the client while the client is asleep Inform the client that because they are on a PCA pump, VS will be taken every 8 hr Teach the client to avoid pushing the button until pain is above a 7 on a scale of 0 to 10 Increase the basal rate and shorten the lock-out interval time if the client's pain level

Instruct the family to refrain from pushing the button for the client while the client is asleep => Even though PCA pumps minimize the risk of overdose, toxic effects could still occur if the client receives more medication than necessary to control pain Monitor a client who is using a PCA pump every 1 to 2 hr during the first 12 hr. The client is at risk for respiratory depression as a result of opioid medication administration Instruct the client to activate the PCA pump when they need it. It is inappropriate for the client to wait until pain escalates to any particular level of intensity before using the pump It is not within the scope of practice for nurse to prescribe the rate and lock-out interval.

A nurse is assessing a client who reports increased pain following physical therapy. Which of the following questions should the nurse ask when assessing the quality of the client's pain? Is your pain constant or intermittent? What would you rate your pain on the scale of 0 to 10? Does the pain radiate? Is your pain sharp or dull?

Is your pain sharp or dull?

A client who is postoperative is verbalizing pain as a 2 on a pain scale of 0 to 10. Which of the following statements should the nurse identify as an indication that the client understands the preoperative teaching they received about pain management? I think I should take my pain medication more often, since it is not controlling my pain Breathing faster will help me keep my mind off of the pain It might help me to listen to music while I'm lying in bed I don't want to walk today bc I have som

It might help me to listen to music while I'm lying in bed

A nurse is caring for a client who reports difficulty falling asleep. Which of the following recommendations should the nurse make? Drink a cup of hot coca before bedtime Maintain a consistent time to wake up each day Exercise 1 hour before going to bed Watch a television program in bed before going to sleep

Maintain a consistent time to wake up each day

A nurse is initiating a protective environment for a client who has had. an allogeneic stem cell transplant. Which of the following precautions should the nurse plan for this patient? Make sure the client's room has at least six air exchanges per hour Make sure the client wears a mask when outside their room if there is construction in the area Place the client in a private room with negative pressure airflow Wear an N95 respirator when giving the client direct care

Make sure the client wears a mask when outside their room if there is construction in the area The nurse should wear an N-95 respirator mask when caring for clients who require airborne precautions, not a protective environment

A nurse on a med-surg unit is caring for a client who has a new prescription for wrist restraints. Which of. the following actions should the nurse take? Pad the client's wrist before applying the restraints Evaluate the client's circulation every 8 hr after application Remove the restraints every 4 hr to evaluate the client's status Secure the restraint ties to the bed's side rails

Pad the client's wrist before applying the restraints Secure the restraint ties to a part of the bed frame that moves with the client to reduce the risk of injury Evaluate the client's circulation, ROM, VS, and overall status every 15 min after initial application of restraints Remove the restraints at least every 2 hr to reposition the client and assess needs for hygiene and toileting

A nurse is using an open irrigation technique to irrigate a client's indwelling urinary catheter. Which of the following actions should the nurse take? Place the client in a side-lying position Instill 15 mL of irrigation fluid into the catheter with each flush Subtract the amount of irrigant used from the client's urine output Perform the irrigation using a 20 mL syringe

Subtract the amount of irrigant used from the client's urine output For a catheter irrigation, the nurse should place the client in a supine or dorsal recumbent position for maximal access to the catheter Open irrigation technique requires instilling 30 to 40 mL of irrigation fluid The nurse should use a 30 - 50 mL syringe to perform open irrigation

A nurse is performing a home safety assessment for a client who is receiving supplemental oxygen. Which of the following observations should the nurse identify as proper safety protocol? The client uses a wool blanket on their bed The client identifies the location of a fire extinguisher The client stores an extra oxygen tank on its side under their bed The client has a weekly inspection checklist for oxygen equipment

The client identifies the location of a fire extinguisher

A nurse in a long term facility is caring for a client who dies during the nurse's shift. Identify the sequence in which the nurse should perform the following steps. 1. Obtain the pronouncement of death from the provider 2. Ask the client's family members if they would like to view the body 3. Remove tubes and indwelling lines 4. Wash the client's body 5. Place a name tag on the body

The first step is to obtain the death pronouncement from the provider.Next, the nurse should remove tubes and indwelling lines prior to cleansing the client's body.After cleansing, the nurse should ask the family members if they wish to view the body. Finally, the nurse should place a name tag on the body before transfer.

A nurse manager is preparing to review medication documentation with a group of newly licensed nurses. Which of the following statements should the nurse manager plan to include in the teaching? Use the complete name of the medication magnesium sulfate Delete the space between the numerical dose and the unit of measure Write the letter U when noting the dosage of insulin Use the abbreviation SC when indicating an injection

Use the complete name of the medication magnesium sulfate

A nurse is caring for a client who has a terminal diagnosis and whose health is declining. The client requests information about advance directives. Which of the following responses should the nurse make? We can talk about advance directives , and I can also give you some brochures about them. You should set up a time to talk with your provider about that Let's discuss how you are feeling today, and we'll save the planning for when you are feeling a little better Why do you want to discuss this

We can talk about advance directives , and I can also give you some brochures about them.

A nurse is caring for a client who is refusing a blood transfusion for religious reasons. The client's partner wants the client to have the blood transfusion. Which of the following actions should the nurse take? Ask the client to consider a direct donation Withhold the blood transfusion Request a consultation with the ethics committee Ask the client's familiy to intervene

Withhold the blood transfusion

A nurse is caring for a client who is scheduled to be transferred to a long-term care facility. The client's family questions the nurse about the reasons for the transfer. Which of the following responses made by the nurse is appropriate? The transfer of your family member is being done bc the provider knows what's best Would you like it if we discussed the transfer with your family member? Why are you so concerned about this transfer? I know how you feel. My parent had to be transferred to a l

Would you like it if we discussed the transfer with your family member?

A nurse is admitting a client who has been having frequent tonic-clonic seizures. Which of the following actions should the nurse add to the client's plan of care? Wrap blankets around all four sides of the bed Apply restraints during seizure activity Place the client in a supine position during seizure activity Have a tongue depressor at the client's bedside

Wrap blankets around all four sides of the bed Turn the client to the side so that the tongue does not occlude the airway and secretions can flow out of the side of the client's mouth Inserting any object into the mouth of a client who is having a seizure increases the risk of injury to the mucous membranes in the mouth and damage to the teeth

A nurse in a surgical suit documentation on a client's medical record that they have a latex allergy. In preparation for the client's procedure, which of the following precautions should the nurse take? Ensure sterilization of nondisposable items with ethylene oxide Wrap monitoring cords with stockinette and tap them in place Cleanse latex ports on IV tubing with chlorhexidine before injecting medication Wear hypoallergenic latex gloves that contain powder

Wrap monitoring cords with stockinette and tap them in place Many monitor devices and cords contain latex. The nurse should prevent any contact of these cords and devices with the client's skin by covering them with a nonlatex barrier material, such as stockinette, and using nonlatex tape to secure them The nurse should use a stopcock for injecting medication. Cleansing a latex item will not remove the latex protein

A nurse is planning an educational program for a group of OA at a senior living center. Which of the following recommendations should the nurse include? You should have an eye examination every 2 years You should receive a tentanus booster every 5 years You should receive a shingles vaccine when you are 70 years old You should receive a pneumococcal vaccine when you are 65 years old

You should receive a pneumococcal vaccine when you are 65 years old