Foundations (PN)

A nurse has received shift report and is preparing her assignment. Which of the following client's should the nurse assess first?

A client who was admitted for chest pain with a troponin level of 0.6 ng/mL and complaining of indigestion

A nurse is caring for a client who frequently attempts to remove his feeding tube. A family member requests that a restraint be applied. Which of the following statements by the nurse is appropriate?

"I will move the tube so he cannot see it."

A nurse is responsible to check that an assistive personnel (AP) uses appropriate personal protection equipment while caring clients. Which of the following statements made by the AP indicates an appropriate understanding of standard precautions techniques?

"I will wear gloves and gown when bathing a client who has open skin lesions."

A nurse is working with several clients in an acute care pediatric unit. Which of the following clients requires the nurse's immediate attention?

An 8-year-old client who had a tonsillectomy and is swallowing frequently

A nurse is caring for a client who is 1 day postoperative following gynecologic surgery and reports incisional pain. Which of the following actions should the nurse take first?

Ask the client to rate her pain on a scale of 0 to 10

A nurse is transcribing a client's prescribed medication orders and is having difficulty reading the written order by the provider. Which of the following nursing action is appropriate?

Contact the provider to clarify the medication order

A nurse is providing dietary teaching to an Asian-American client who is gazing at the floor during the instruction. Which of the following actions would demonstrate culturally sensitive nursing care?

Continuing with the discussion

A nurse is monitoring a client for complications of immobility. Which of the following does the nurse expect to find?

Contractures of extremities Crackles in the lungs Pressure ulcers

A nurse is using standard precautions while caring for a group of clients. Which of the following situations would require that the nurse wear protective eye equipment?

Drawing cord blood from a neonate Suctioning a child who has a newly placed tracheostomy tube

A nurse is caring for a client who is requesting prescription pain medication. Which of the following actions should the nurse perform first?

Determine the location of the pain

A nurse is caring for a client who has an exacerbation of gout. When collecting data from the client, which of the following joint alteration should the nurse expect to observe?

Hyperemia Erythema Tophi Decreased mobility

A nurse is caring several clients at various developmental stages. The nurse understands that according to Erikson, acceptance of death occurs at which of the following stages of psychosocial development?

Integrity versus Despair

A nurse is caring for a client who is on contact infection control precautions. Which of the following interventions by the nurse is appropriate?

Maintain frequent contact with the client

A nurse is admitting a client that reports flu-like symptoms with hyperactive reflexes along with a new onset of confusion. The nurse realizes that the client is experiencing which of the following imbalances?

Metabolic alkalosis

A nurse working in an extended-care facility is reinforcing for a group of newly licensed nurses about the expected physiologic changes of aging. Which of the following information should the nurse include?

Older adults have more difficulty seeing when there is a low level of light or glare Vital capacity of the lungs declines nearly 50% between ages of 20 and 70 Bladder capacity decrease and the kidneys become less efficient with age

A nurse is caring for a client who is receiving heat applications using an aquathermia pad. Which of the following is an appropriate action when applying the pad?

Place a thin towel over the affected area before application

A nurse is caring for a client with limited hand movement. Which of the following actions should the nurse take to assist the client with feeding?

Provide an adaptive feeding device for the client

A nurse observes an assistive personnel (AP) taking the call light away from a client and reprimanding him for using it frequently. Which of the following actions should the nurse take first?

Reassure the client

A nurse is caring for an older adult client who has a fractured hip and will require rehabilitative care. The client's family asks the nurse for information about this type of care. Which of the following statements is appropriate?

Rehabilitation began with the client's admission to the hospital

A nurse is assisting with the development of a plan of care for an older adult who is at risk for falls. Which of the following actions should the nurse include in the plan?

Reinforcing teaching about balance and strengthening exercises. Providing information about home safety checks. Locking beds and wheelchairs during transfers. Placing a bedside table within the client's reach.

A nurse is documenting information in a computerized medical record. Which of the following nursing actions may jeopardize the confidentiality?

Share passwords for computer access with colleagues

During an admission interview, a client reports to the nurse using several herbal and vitamin supplements daily, including echinacea. The nurse recognizes that echinacea is a popular herb used by clients primarily to

Stimulate the immune system

A nurse is caring for a child and identifies an extravasation at the intravenous site. Identify the order the nurse should perform the following actions.

Stop the infusion Elevate the extremity Notify the provider Perform prescribed treatment Remove the IV line

A nurse is working a night shift and caring for several clients at risk for falls. Which of the following actions should the nurse take?

Teach the clients to use the call light Place a fall risk sign above the clients beds

A nurse is preparing an inservice for a group of newly licensed nurses about organ donation. Which of the following information should the nurse include?

The nurse may serve as a witness to a consent for organ donation

The nurse is caring for an unconscious client. The nurse understands that the side-lying position is recommended for this client to

prevent aspiration problems

The nurse is caring for a client who has pneumonia. Which of the following actions should the nurse take to thin the client's respiratory secretions?

Encourage regular use of the incentive spirometer

A nurse is collecting data on an intravenous site located in the left hand of an infant. Which of the following findings indicate an inflitration?

Edema in the palm of the hand

A nurse is reinforcing teaching with a group of assistive personnel (AP) about hand hygiene. Which of the following statements by one of the APs indicates a need for further teaching?

"As long as I am changing gloves between clients, it is not necessary to wash my hands."

A nurse is caring for a client who has received an electrical burn. With permission from the client, the nurse is answering questions from the family. Which of the following is an appropriate response to the family's concerns?

"He has received an electrical burn. His condition is stable, and we will update you with any changes."

A nurse is reinforcing teaching to a client about home use of transdermal medication. Which of the following statements by the client indicates understanding of the teaching?

"I will clean and dry the area before applying the patch"

A nurse provides teaching to a client on proper hearing aid use. Which of the following statements indicates a need for further instruction?

"I will clean the hearing aid with alcohol wipes."

A nurse in a clinic is reinforcing teaching to a group of clients about preventing low back pain and injury. Which of the following statements by a client requires clarification?

"I will do exercises that strengthen my upper body and abdominal muscles."

When planning a home discharge for a client who has quadriplegia, the nurse suggests that the family might need respite care services. When a family member asks how respite care can help, which of the following responses is appropriate?

"Respite care allows the primary caregiver time away day-to-day care responsibilities"

Intake: 4 oz of clear soda, 1 piece of toast, 12 oz of water, 1 cup of fruit-flavored gelatin, 1/2 cup of chicken broth, 300 ml of 0.9% sodium chloride IVOutput: 460 mL of urine, 90 mL of drainage from the suction drainage system. What should the nurse document as the client's intake?

1,140 mL

A nurse is caring for a client who is receiving oxygen at 2 L/min via a nasal cannula. What oxygen concentration is the client receiving?

28%

A nurse is caring for an infant who is prescribed amoxicillin (Amoxil) 320 mg PO every 12 hr. The medication is available as 400 mg/5 mL. How many mL will the nurse administer?

4 mL

The nurse is caring for an adult client with constipation. Which nursing intervention is appropriate

Add fluid and fiber to the diet

A nurse is preparing to suction a client who has a tracheostomy

Adjust the suction to 100 to 150 mm Hg Don sterile gloves Check function of suction catheter Hyperoxygenate client Insert the catheter without suction Apply intermittent suction while rotating the catheter Assess for clearance of secretions

A nurse is preparing a client for ambulatory surgery. After the nurse places an IV line, the client reports that the IV is painful. Which of the following actions should the nurse take?

Attempt to reinsert an IV into a new site

A nurse is caring for a client with metabolic alkalosis. Which of the following clinical manifestations should the nurse monitor for?

Bicarbonate excess Hyperactive reflexes

A nurse is attending a cardiopulmonary resuscitation (CPR) class. When performing CPR for an infant, the nurse should evaluate circulation by palpating which of the following pulses?

Brachial

A nurse is preparing to administer an enema when the client states, "My doctor didn't tell me I was supposed to receive an enema." Which of the following actions is appropriate for the nurse to take?

Check the client's chart for the provider's prescription

A client receiving a cleansing enema reports mild cramping. After a few minutes, he asks the nurse to stop the enema and allow him to go the bathroom. Which of the following is an appropriate nursing action?

Clamp the enema tubing briefly

A nurse is caring for a client who is postoperative following abdominal surgery. The surgeon initially prescribes a clear liquid diet. Which of the following items should the nurse include on the client's lunch tray?

Cranberry juice

A nurse is caring for a client with the following arterial blood gases: HCO3 of 18 mEq (22-26), CO2 of 28 mmHg (35-45). Which of the following pH values and acid base imbalances would accompany these values?

Decreased pH and metabolic acidosis

A nurse is preparing to discontinue a client's urinary catheter. Which of the following is the nurse's priority action?

Deflating the balloon prior to catheter removal

A nurse is reviewing the plan of care of a non-English speaking client. Which of the following intervention should the nurse suggest for inclusion in the plan of care?

Determine the client's level of fluency in their primary language

A nurse is assisting a client who is postoperative with ambulation. While ambulating with the nurse, the client feels fain and starts to fall. Which of the following is an appropriate action by the nurse?

Ease the client gently to the floor

A nurse is caring for an older adult client who reports constipation. Which of the following is an appropriate nursing recommendation?

Eat raw vegetables

A nurse is providing care to a client who has become increasingly anxious and confused. Which of the following actions should the nurse implement to avoid the use of physical restraints?

Ensure effective pain management Attend to the needs for toileting Assign the client to a room near the nurse's station Orient client frequently to the environment

A provider is discharging a client with a prescription for home oxygen therapy. Reinforcement of client and family teaching by the nurse should include which of the following instructions?

Ensure that the straps on the mask are secure but not too tight Check the tops of the ears regularly for skin breakdown Post "no smoking" warning signs at home in a prominent location

A nurse is reinforcing teaching to a client who is experiencing constipation. Which of the following should the nurse discuss as causes of constipation?

Excessive laxative use Ignoring the urge to defecate Inadequate fluid intake

A nurse is caring for a client who reports difficulty sleeping while in the hospital. Which of the following actions performed by the assistive personnel (AP) while the client is sleeping should prompt the nurse to intervene?

Flushes the client's toilet after emptying the urinary catheter drainage bag

A nurse is preparing an inservice for a group of newly licensed nurses about client confidentiality. The nurse should explain that they may share a client's protected health information with which of the following groups?

Health care team members caring for the client

As the nurse prepares a newly admitted female, older adult client for bed, the client says, "I am afraid that I may fall getting to the bathroom during the night. I tend to get a bit disoriented in new surroundings." Which of the following nursing actions is appropriate?

Keep the night light on in the client's room

A nurse is completing a client's history and physical examination. Which information should the nurse consider subjective data?

Nausea

A nurse is caring for a client with a diagnosis of Clostridium difficile (C. difficile). Which of the following cleansing agents is most appropriate for hand hygiene?

Nonantimicrobial soap

A nurse is caring a client with hemophilia and has hemarthrosis of the left knee. In addition to initiating an IV line, which of the following action should the nurse take?

Obtain a stool specimen

A nurse is caring for a client who has been on strict bed rest for 1 week. Which of the following findings indicates client readiness to ambulate?

Performs active range of motion exercise to all extremitites

A student nurse is performing postmortem care on a Muslim client. Which of the following actions by the student nurse should prompt a nurse to intervene?

Prepares to cleanse the body

A nurse is caring for a client who has contact dermatitis of the neck and upper chest. Which of the following is an expected finding?

Reports of exposure to a skin irritant

A nurse is collecting data from a client who has narcolepsy. Which of the following is an expected finding?

Sudden attacks of sleep Sleep-wake cycle hallucinations

A nurse receives a client care assignment that he believes is unfair. Which of the following is an appropriate action for him to take?

Talk with the charge nurse about the assignment and his concerns

The practical/ vocational nurse notes that the left eyelid of an unconscious client remains partly open. Which nursing measure provides protection for the eye?

Tape the eyelid shut

A nurse is caring for an alert and competent older adult who comes to the hospital accompanied by her son for elective cataract extraction. Who should the nurse have sign the consent form for the surgical procedure?

The client

A nurse is completing an admission database. Which of the following nonverbal client cues should the nurse recognize as a response to stress?

The client does not maintain eye contact.

A nurse in a long term care facility is assisting a client with eating during meal time and recognizes another client indicating he is choking. Which of the following situations requires immediate intervention by the nurse?

The client is not making any sounds

A nurse is discussing gender-related factors that affect communication. Which of the following is a characteristic of men when communicating with others?

They are more goal-oriented when discussing issues

A nurse is caring for a client who has a large surgical wound healing by secondary intention. The nurse should recommend a diet high in protein and

Vitamin C

An assistive personnel (AP) is obtaining a client's oral temperature. The client informs the AP that he has just had some ice chips. Which of the following is an appropriate action by the AP?

Wait 15 min and return to take the oral temperature

A charge nurse is observing a less experienced nurse administer a Mantoux tuberculin skin test. The charge nurse should intervene when the less experienced nurse does which of the following?

Withdraws the needle and massages the site gently

A nurse should share her password for access to the facility's computer system with

no one

A nurse is caring for a client who has osteomyelitis. The client states "I am a practicing Seventh Day Adventist, and an elder in my church." In response to the client's statement, which of the following questions would be appropriate to ask the client? "Will you need

vegetarian meals?"