Foundations of Nursing Final
A nurse is assessing a client who reports frequent vomiting and diarrhea for the past 3 days. Which of the following findings should the nurse expect? (Select all that apply) A) Poor skin turgor B) Bradycardia C) Hypotension D) Pale yellow urine E) Flat neck veins
A) Poor skin turgor Frequent vomiting and diarrhea cause dehydration, which manifests as skin that lacks elasticity C) Hypotension Frequent vomiting and diarrhea cause dehydration, which manifests as tachycardia E) Flat neck veins Frequent vomiting and diarrhea cause dehydration, which manifests as flat neck veins when the client is lying supine
A nurse receives a client care assignment from the charge nurse that he believes is unfair. The nurse voices his concern to the charge nurse. The nurse is using which level of communication at this time? A) Transpersonal B) Intrapersonal C) Interpersonal D) Public
C) Interpersonal Interpersonal communication is face-to-face interaction with another person. It results in an exchange of ideas, problem solving, expression of feelings, decision-making and personal growth
A nurse is adhering to standard precautions while caring for a group of clients. For which of the following tasks should the nurse wear protective eye equipment? (Select all that apply) A) Providing hygiene care to a client who is HIV-positive B) Emptying a urinary drainage bag for a client who has pneumonia C) Irrigating a client's abdominal wound D) Transporting a cerebrospinal fluid specimen to the laboratory E) Suctioning a client's new tracheostomy tube
C) Irrigating a client's abdominal wound is correct The nurse should wear protective eyewear when irrigating a wound because wound exudate and fluids could splash into her eyes E) Suctioning a client's new tracheostomy tube is correct The nurse should wear protective eyewear when performing tracheal suctioning because the client's secretions could splash into her eyes
A nurse is assessing an older adult client who has osteoporosis. Which of the following spinal deformities should the nurse expect to find in this client? A) Lordosis B) Ankylosis C) Kyphosis D) Scoliosis
C) Kyphosis Kyphosis, a forward "stooping" posture with a loss of height, is an angulation of the posterior curve of the thoracic spine, usually a result of osteoporosis. It is most common in older adults and increases with aging and vertebral fractures
A nurse is caring for an older adult client ho states, "I am afraid that I may fall while walking to the bathroom during the night." Which of the following actions should the nurse take? A) Limit the client's fluid intake in the evening B) Obtain a bedside commode for the client's use C) Leave a nightlight on in the client's room D) Put the side rails up and tell the client to call the nurse before voiding
C) Leave a nightlight on in the client's room This is an appropriate action for keeping the client safe. Night vision ma be impaired in older adult clients. If the client awaken s
A nurse is caring for a client who has a hip fracture that requires surgical repair. Which of the following health care professionals is responsible for obtaining informed consent from the client for the procedure? A) Nurse B) Anesthesiologist C) Surgeon D) Surgical suite nurse
C) Surgeon The health care provider who will perform the treatment or procedure is responsible for obtaining informed consent from the client. The surgeon who is performing the surgical repair of the fracture would be responsible for obtaining informed consent
A nurse is caring for a client who has fallen while getting out of bed and states, "I'm okay! I guess I should have called for help to the bathroom." After assessing the client, the nurse notifies the provider. Which of the following documentation should the nurse include in the client's medical record? A) "There were no injuries sustained" B) "An incident report was completed C) "An incident report was forwarded to risk management" D) "The provider was notified"
D) "The provider was notified" Nursing intervention that support factual information should be documented in the health record
A provider prescribes a sublingual medication for a client who has an NG tube in place. Which of the following actions should the nurse take? A) Request a prescription for an oral formulation of the medication B) Administer the crushed medication through the NG tube C) Dissolve the medication in water and give it through the NG tube D) Administer the medication under the client's tongue
D) Administer the medication under the client's tongue The nurse should administer the sublingual medication under the client's tongue. Sublingual preparations work via direct absorption into the bloodstream. Swallowing it exposes it to gastric juices which can inactivate the medication
A nurse is caring for an older client who has a urinary tract infection (UTI). Which of the following manifestations should the nurse identify as a finding specifically associated with this client? A) Urinary retention B) Low back pain C) Incontinence D) Confusion
D) Confusion Confusion is a clinical finding of UTIs specifically associated with older adult clients
A nurse manager is reviewing the Good Samaritan laws with a group of newly licensed nurses. Which of the following statements by the nurse manager is appropriate? A) "If you render aid in an accident, do not leave the scene until another competent person can take over" B) "Good Samaritan laws prohibit the victim from filing a lawsuit against the nurse" C) "Federal laws require a licensed nurse to render aid in an emergency" D) "A nurse who volunteers at a summer camp for children is covered by Good Samaritan laws"
A) "If you render aid in an accident, do not leave the scene until another competent person can take over" Once the nurse renders aid, she has entered a nurse-client relationship and must continue to provide care until competent help arrives
Which of the following situations could pose a threat to a client's personal hygiene? A) A client has a newly formed ileostomy B) A client who performs meticulous foot care C) A German client refuses to bathe everyday D) The room temperature is set at 72 F
A) A client has a newly formed ileostomy Some of the factors that influence one's personal hygiene are social practices, body image, knowledge of physical condition and cultural variables. A client who has had an ileostomy has had a body image change which can greatly influence whether he will care for it or rely on others. This can pose a threat if client chooses not to care for it
A nurse is reviewing the medical records of four clients who have an acid-base imbalance. The nurse should recognize that which of the following clients is at risk for metabolic acidosis? A) A client who has diarrhea B) A client who is vomiting C) A client who is taking a thiazide diuretic D) A client who has salicylate intoxication
A) A client who has diarrhea Diarrhea can cause metabolic acidosis due to the loss of bicarbonate
A nurse is caring for a client who is immobile. Which of the following actions is the priority for the nurse to include in the client's plan of care? A) Auscultate breath sounds at least every 2 hr B) Perform range-of-motion (ROM) exercises at least two to three times daily C) Make sure the client has an intake of 2,000 to 3,000 mL of fluid per day D) Apply antiembolic stockings
A) Auscultate breath sounds at least every 2 hr The priority action the nurse should contribute to the plan of care when using the airway, breathing, circulation approach to client care is auscultating breath sounds to determine the client's need for suctioning. With inactivity, secretions can pool in the airways, diminishing breath sounds and causing crackles and dyspnea
A nurse is caring for a client who has an eating disorder. The nurse is practicing which of the following ethical concepts when the client refuses to drink a between meal protein and calorie supplement? A) Autonomy B) Beneficence C) Veracity D) Fidelity
A) Autonomy Autonomy respects the rights of clients to refuse medication or treatment
A nurse enters a client's room and finds the client pulseless. The family has requested do-not-resuscitate (DNR) order from the provider, but he has not written the order yet. Which of the following actions should the nurse take? A) Call the emergency response team B) Seek immediate help from the risk manager C) Call the provider for a stat DNR order D) Respect the family's wishes and do nothing
A) Call the emergency response team Unless the provider writes a DNR order, the nurse should make every effort to revive the client. The nurse should follow the facility's protocol for enacting the emergency response procedure
A nurse is providing nail care for a client. Which of the following actions should the nurse take? A) Clean under the nail with an orange stick B) File the nails in a rounded shape C) Push the cuticles back with a metal nail file D) Trim the nails at the lateral corners
A) Clean under the nail with an orange stick The nurse should use an orange stick to push back the cuticle and clean under the nail
A nurse on a medical unit is caring for a client who suddenly becomes confused and drowsy. Additional data includes pulse 100/min, respiratory rate 24/min, BP 132/76 mm Hg, and temperature 36.8 C (98.2 F). Which of the following actions should the nurse perform? A) Complete a neurological check B) Administer the prescribed PRN antihypertensive medication C) Increase the client's fluid intake D) Hold the client's evening dose of digoxin
A) Complete a neurological check Neurological assessment is an appropriate nursing intervention when a client displays sudden confusion. Sensory alterations can occur when a client is experiencing multiple sensory stimuli and can result in inappropriate sensory responses. Tolerance to stimuli may be affected by fatigue and emotional and physical well-being
A nurse is caring for an older adult client. The nurse should recognize the client is at risk for which of the following physiological changes? (Select all that apply) A) Decreased gastric motility B) Decreased skin elasticity C) Increased pain threshold D) Increased metabolic rate E) Increased cardiac output
A) Decreased gastric motility Older adults can have an increase in gastric pH, a decrease in gastric blood flow, and a decrease in gastric motility, which can alter oral medication absorption B) Decreased skin elasticity Older adults can have a decrease in skin elasticity that can increase the risk for skin breakdown and injury C) Increased pain threshold Older adults can have an increase in sensation of pain, temperature, and touch
A nurse is planning care for a hospitalized client who is immobile and in a continuous mitten restraint. Which of the following interventions should be included in the client's care plan? (Select all that apply) A) Document restraint checks and client status every 2 hr B) Educate the client's family about restraint use C) Obtain the provider's prescription renewal every 72 hr D) Implement passive range-of-motion exercises E) Release the restraint and reposition the client every 4 hr
A) Document restraint checks and client status every 2 hr Documentation of restraint checks and client status should take place at least every 2 hr B) Educate the client's family about restraint use It is important for the client's family to understand the purpose of the restraint D) Implement passive range-of-motion exercises Passive range-of-motion exercises promote circulation and prevent skin breakdown and contractures
A nurse is caring for a client in the orientation phase of the nurse-client relationship. Which of the following communication techniques should the nurse use during this phase? A) Elicit information from the client B) Encourage the client to use slef-exploration C) Review the client's progress toward personal objectives D) Talk with others who have information about the client
A) Elicit information from the client Obtaining information from the client is a component of the orientation phase
A nurse has completed care procedures for a client who requires airborne precautions. Which of the following items of personal protective equipment (PPE) should the nurse remove last? A) Mask B) Gloves C) Gown D) Goggles
A) Mask With a client who requires airborne precautions, the nurse will continue to need the protection of the mask while removing other contaminated PPE
A nurse is caring for a client who has the following arterial blood gas results: HCO3 18 mEq, PaCO2 28 mm Hg and pH 7.30. The nurse recognizes the client is experiencing which of the following acid base imbalances A) Metabolic acidosis B) Respiratory acidosis C) Metabolic alkalosis D) Respiratory alkalosis
A) Metabolic acidosis A client experiencing metabolic acidosis would have a decreased pH, a decreased HC)3 and a decreased PaCO2
A nurse is assessing a client who has a sodium level of 116 mEq/L. Which of the following findings should the nurse expect? A) Nausea and vomiting B) Extreme thirst C) Flushed skin D) Fever
A) Nausea and vomiting A sodium level of 116 mEq/L is a critical value indicating hyponatremia. Nausea and vomiting are expected findings for a client with this sodium level
A nurse is monitoring a client who is postoperative and unable to respond to questions. Which of the following nonverbal behaviors should the nurse identify as an indication that the client has pain? (Select all that apply) A) Restlessness B) Grimacing C) Moaning D) Clenching E) Drowsiness
A) Restlessness Clients who have uncontrolled pain often become restless and anxious in response to the discomfort B) Grimacing Facial movements such as grimacing, tightly closing the eyes, and biting the lower lip are behavioral indicators of pain D) Clenching Clenching the teeth and biting the lower lip are common findings in clients who have pain
A nurse is assessing a client's cardiovascular system. To palpate for unexpected pulsations in the pulmonic area, at which anatomical location should the nurse place her fingers? A) The left second intercostal space B) The right second intercostal space C) The left fifth intercostal space D) The left fifth intercostal space at the midclavicular line
A) The left second intercostal space The left second intercostal space is the location where the nurse can palpate pulsations at the pulmonic valve area. This is the site for palpating lifts and heaves in this area
A nurse is reviewing the laboratory results of a client who has fluid volume deficit. The nurse would expect which of the following findings? A) Urine specific gravity 1.035 B) Hematocrit 44% C) BUN 19 mg/dL D) Sodium 155 mEq/L
A) Urine specific gravity 1.035 A client experiencing fluid volume deficit would manifest an increased urine specific gravity greater than 1.030
A nurse is planning to use the SBAR communication tool when calling a provider. Which of the following statements should the nurse include in the B step? A) "The client should be seen by a neurologist" B) "The client was found unconscious on the floor in her home" C) "There are no provider's prescriptions available" D) "The client is disoriented. Pupils are slow to respond to light"
B) "The client was found unconscious on the floor in her home" This statement is the background or context of the situation, which is the B step in the SBAR tool. The background portion should provide information that is pertinent to the current situation
A nurse is assessing a client for pitting edema and notes an indentation of 6 mm (0.25 in) at the point of pressure. Which of the following notations should the nurse use to document the severity of the client's edema? A) 4+ B) 3+ C) 2+ D) 1+
B) 3+ The nurse should document pitting edema of 5 to 7 mm as 3+
A nurse is preparing to perform hand hygiene. Which of the following actions should the nurse take? A) Adjust the water temperature to feel hot B) Apply 4 to 5 mL of liquid soap to the hands C) Hold the hands higher than the elbows D) Rub hands and arms to dry
B) Apply 4 to 5 mL of liquid soap to the hands The nurse should apply 4 to 5 mL of liquid soap to the hands to ensure an adequate amount is available to produce lather and kill microorganisms
A nurse is caring for a client who has active pulmonary tuberculosis (TB). The client requires airborne precautions and is receiving multidrug therapy. Which of the following precautions should the nurse take to transport the client safely to the radiology department for a chest x-ray?
B) Have the client wear a mask When a client who has a communicable disease must leave his room, it is important to protect everyone with whom the client comes in contact. Having the client wear a mask protects others from airborne particles should the client cough
A nurse is providing care to a client who is on strict bed rest following surgery. The nurse assists the patient to the bedside commode and the client sustains an injury to the operative area. Which of the following types of torts has the nurse committed? A) Battery B) Negligence C) Invasion of privacy D) Assault
B) Negligence Negligence is that failure to provide the expected standard of care. The expected standard of care was strict bedrest
An 86 year old client with Alzheimer's disease continually tries to get out of bed at night. Which alternative safety measure would the staff choose to use with this client? A) Explain all the procedures and treatments B) Place a bed safety monitoring device on the bed C) Orient the client to her surroundings D) Use relaxation techniques
B) Place a bed safety monitoring device on the bed Alzheimer's disease causes impaired intellectual functioning, so a safety device that is weight sensitive would alert the nurse when the client is trying to get out of bed
A nurse is preparing for the admission of client who has suspected active tuberculosis. Which of the following precautions should the nurse plan to implement to safely care for this client? A) Have staff and visitors wear gowns, masks, and gloves while in the client's room B) Place the client in a private room with a special ventilation system C) Assign the client to a room with other clients who require droplet precautions D) Modify the protocol for donning and removing personal protective equipment before entering or leaving the client's room
B) Place the client in a private room with a special ventilation system Clients who have active tuberculosis should be assigned to private rooms with negative-pressure airflow via HEPA filtration systems. In these rooms, the air is not returned to the inside ventilation system but it filtered and exhausted directly to the outside
A nurse is giving a presentation about client confidentiality to a group of newly licensed nurses. Which of the following actions is an example of a violation of confidentiality? A) Discussing a client's surgical procedure with the nurse manager B) Reporting laboratory findings to a member of the client's family C) Notifying the provider of physical examination findings D) Identifying the client by name when making a referral for home health services
B) Reporting laboratory finding to a member of the client's family Confidentiality is the nondisclosure of information except to an authorized person, that is, someone involved in the client's care of someone the client has given permission for informing. Reporting laboratory findings to a family member without the client's permission violates client confidentiality
A home health nurse is assessing an older client in the home who has decreased vision due to a history of glaucoma. Which of the following findings should the nurse identify as a safety risk? A) Electrical cords are placed along the walls B) Scatter rugs are present in the kitchen C) Handrails are present in the bathroom D) Uses a microwave for cooking
B) Scatter rugs are present in the kitchen Scatter rugs in the kitchen are a safety hazard. The client could trip on one of the rugs and fall due to impaired vision
A nurse enters the room of a client who becomes verbally abusive. Which of the following actions should the nurse take? A) Inform the client of consequences B) Speak slowly in a low, calm voice C) Forbid the client from speaking in an abusive manner D) Remain a stance of 1 ft away from the client
B) Speak slowly in a low, calm voice Speaking in this manner conveys to the client that the nurse is controlled, nonthreatening, and caring
A nurse is caring for a client who is scheduled for an elective surgical procedure. Which of the following actions should the nurse take regarding informed consent? A) Obtain the client's consent B) Witness the client's signature C) Explain the risks and benefits of the procedure D) Explain the procedure to the client if they do not understand
B) Witness the client's signature It is the nurse's responsibility to witness the client's signing of the consent form, and to verify that the client is consenting voluntarily and appears to be competent to do so
A nurse is assessing a client who has insomnia. Which of the following questions is the highest priority for the nurse to ask the client? A) "Are there any specific factors that you think are affecting you ability to sleep?" B) "Can you describe your bedtime routine to me?" C) "Do you have difficulty staying awake when you are driving?" D) "When did you begin to have trouble sleeping?"
C) "Do you have difficulty staying awake when you are driving?" This question addresses the greatest risk to the client, which is safety, and is therefore the priority question
A nurse is applying a cold compress for a client who has pain and minor swelling in a sutured laceration on the forearm. Which of the following assessments should the nurse use to determine the treatment is effective? A) Inspecting the site for reduced swelling B) Monitoring the client's pulse rate C) Asking the client to rate the pain D) Having the client perform range-of-motion of the affected arm
C) Asking the client to rate the pain Pain is a subjective experience. The nurse should encourage the client to quantify the pain on a pain scale before, during, and after cold application to determine its effectiveness
A nurse is assessing for cyanosis in a client who has dark skin. Which of the following sites should the nurse examine to identify cyanosis in this client? A) Pinnae of the ears B) Dorsal surface of the hand C) Conjunctivae D) Dorsal surface of the foot
C) Conjunctivae To assess skin color changes in clients who have dark skin, the nurse should examine body areas with minimal pigmentation, such as the sclerae, soles of the feet, conjunctivae, and mucous membranes
A nurse is planning care for 2-month-old infant following a surgical procedure. Which of the following pain rating scales should the nurse plan to use to determine the infant's level of pain? A) FACES scale B) OUCHER scale C) FLACC scale D) PANAD scale
C) FLACC scale The FLACC scale is used for children 2 months to 7 years. It uses facial expressions, leg movement, activity, cry, and consolability to assess the client's level of pain
A nurse is having difficulty caring for a client due to variables affecting the communication process. Which of the following should the nurse identify as an interpersonal variable? (Select all that apply) A) Education B) Feedback C) Gender D) Perception E) Time
C) Gender Gender is an interpersonal variable that affects the communication process. Other interpersonal variable are sociocultural background, health status, emotions, pain, and relationships D) Perception Perception provides a uniquely personal view to a client's experience and is an interpersonal variable that affects communication. Other interpersonal variable are sociocultural background, health status, emotions, pain, and relationships
A nurse is admitting a client who is arriving back to the unit from the PACU following hip arthroplasty. Which of the following tasks should the nurse assign to the assistive personnel (AP)? A) Obtain initial vital signs B) Determine if the client is in need of pain medication C) Record the amount of urine in the catheter drainage bag D) Instruct the client on the use of the incentive spirometer
C) Record the amount of urine in the catheter drainage bag Recording output is within the scope of practice of the AP
A nurse is caring for a client who is postoperative following abdominal surgery and reports incisional pain. The surgeon has prescribed morphine 4 mg IV bolus every 6 hr as needed. Before administering this medication, the nurse should complete which priority assessment? A) Blood pressure B) Apical heart rate C) Respiratory rate D) Temperature
C) Respiratory rate The priority action the nurse should take when using the airway, breathing, and circulation (ABC) approach to client care is to evaluate the client's respirations. The respiratory rate is especially important because opioid analgesics like morphine can cause respiratory depression
A nurse on a medical unit is teaching a group of assistive personnel about handling clients' bed linens safely. Which of the following instructions should the nurse include? A) Return any fresh linen not used for a client to the linen supply area B) Use double bagging to remove soiled linen from the client's room C) Tie linen bags securely at the top D) Fill linen bags with as much soiled linen as possible
C) Tie linen bags securely at the top This action secures the linen inside the bag, keeping any soiled linen from contaminating surfaces or the hands of whoever has to pick it up and bag it again
A nurse administers an incorrect medication to a client. Following an assessment of the client, the nurse determines that the client has experienced no untoward effects as a result of the medication. The nurse does not complete an incident report because no harm came to the client. Which of the following ethical principles did the nurse violate? A) Autonomy B) Beneficence C) Veracity D) Confidentiality
C) Veracity Veracity is the duty to tell the truth. The nurse violated the ethical principle of veracity when choosing not to report the error instead of being truthful
A nurse is assessing a client who has hypokalemia as a result of nausea, vomiting, and diarrhea. Which of the following findings should the nurse expect? A) Hyperactive reflexes B) Extreme thirst C) Weak, irregular pulse D) Hyperactive bowel sounds
C) Weak, irregular pulse Common manifestations of potassium depletion include a weak and irregular pulse, muscle weakness, fatigue, and ventricular dysrhythmias
A nurse is teaching a client's adult sun about how to position the client when administering enteral feedings at home. Which of the following statements by the son indicates an understanding of the teaching? A) "I will allow him to be in the position where he is most comfortable during the feeding" B) "I will elevate the head of the bed 10 degrees during the feeding" C) "I will turn him on his left side during the feeding" D) "I will have him sit in his chair during the feeding"
D) "I will have him sit in his chair during the feeding"
A nurse is admitting a client who has a partial hearing loss. Which of the following is the priority action by the nurse? A) Speak using his usual tone of voice B) Stand directly in front of the client C) Rephrase statements the client does not hear D) Determine if the client uses hearing aids
D) Determine if the client uses hearing aids The first action the nurse should take using the nursing process is to assess the client. The nurse should find out if the client has hearing aids and whether they are in place and functioning
A nurse is caring for a client who refuses treatment and asks to be discharged from the hospital against medical advice. The nurse notifies the client's provider, who tells the nurse to restrain the client, if necessary, to keep her from leaving the hospital. The nurse understands that restraining this client would be considered which type of civil action by the nurse? A) Invasion of privacy B) Assault C) Battery D) False imprisonment
D) False imprisonment False imprisonment is detaining a client against her will to seek freedom. The client has the right to refuse treatment against medical advice and leave the hospital
A nurse is assessing a preschooler who has a calcium level of 8.0 mg/dL. Which of the following findings should the nurse expect? A) Dry, sticky mucous membranes B) Polyuria C) Negative Chvostek's sign D) Muscle tremors
D) Muscle tremors A serum calcium level of 8.0 mg/dL is below the expected reference range. A preschooler who has hypocalcemia is likely to have muscle tremors and cramps that can progress to tetany and convulsions
A charge nurse is observing a nurse auscultating a client's bowel sounds. Which of the following actions requires intervention by the charge nurse? A) Clamps the NG tube during auscultation B) Performs auscultation between meals C) Auscultates bowel sounds for 3 to 5 min D) Palpates the abdomen prior to performing auscultation
D) Palpates the abdomen prior to performing auscultation The nurse should auscultate the abdomen prior to palpating it to prevent altering the bowel sounds. Both percussion and palpation can stimulate the intestines, increase their motility, and intensify the bowel sounds
A nurse is setting goals for a client who has AIDS and is at the end of life. Which of the following are realistic goals? A) The client will verbalize an understanding of the mode of disease transmission B) The client will experience a weight gain of one to two pounds per week C) The client will increase attendance at community social activities D) The client will receive medication to minimize episodes of breakthrough pain
D) The client will receive medication to minimize episodes of breakthrough pain The client should receive medication to minimize episodes of breakthrough pain as a goal for the end of life care
A nurse is auscultating the breath sounds of a client who has asthma. When the client exhales, the nurse hears continuous high-pitched squeaking sounds. The nurse should document this as which of the following adventitious breath sounds? A) Crackles B) Rhonchi C) Stridor D) Wheezes
D) Wheezes Wheezes are continuous, high-pitched squeaking sounds, first evident on expiration, but possibly evident on inspiration as the airway obstruction of asthma worsens. Wheezes are often audible without a stethoscope
A nurse is admitting a client from a long-term care facility. The nurse should use closed-ended questions when assessing which of the following factors? A) When determining if the client is eating a well-balanced diet B)When asking the client about his receptiveness to the transfer C) When asking the client how he completes his ADLs D) When asking if the client took his medications this morning
D) When asking if the client took his medications this morning A "yes" or "no" response is sufficient when asking if a client took his morning medications. If he did not take them and should have, the nurse might want to explore the issue further
