Fundamentals 2

A client who has heart failure and is receiving 100% oxygen via partial re breather mask

A nurse is caring for a group of clients who are receiving oxygen therapy. Which of the following client should the nurse plan to see first

lower abdomen

I nurse is preparing to anchor with tape to the catheter tube for a male client who has a newly inserted indwelling urinary catheter. At which of the following locations should the nurse take the catheter

Exert pressure on the bony prominence's when holding the eyelids open

A nurse is performing eye irrigation for a client who is exposed to smoke and ash. Which of the following actions should the nurse take

Hold breath for five seconds after goal volume is reached

A nurse is reinforcing teaching with a client who is recovering from gallbladder surgery about how to use an incentive spirometer. Which of the following information should the nurse include in teaching

Don clean gloves to remove the old dressing

A nurse is replacing the surgical dressing on a client who had abdominal surgery. Which of the following actions should the nurse take

Elevate the client's head of bed 45 degrees before the feeding.

A nurse is caring for a client who has an NG tube for intermittent enteral feedings. Which of the following actions should the nurse take

Collapse the device of air after afternoon

A nurse is caring for a client who has had a mastectomy and has a self suction drainage evacuator in place. Which of the following actions should the nurse take to ensure proper operation of the device

Insert the tip of the tubing 8 cm (3.1 in)

A nurse is administering a cleansing enema to a client who is scheduled for a diagnostic procedure. Which of the following actions should the nurse take

Turn the stocking inside out up to the heel before applying

A nurse is applying antiembolitic stockings for a client who has a history of deep vein thrombosis. Which of the following actions should the nurse take when applying the stockings

Determine whether the client is able to breathe

A nurse is assisting a client who is eating at mealtime. The client grabs her neck with both hands and appears frightened. Which of the following actions should the nurse take first

A nurse is caring for a client who has a prescription for the collection of a sputum specimen for culture and sensitivity. Which of the following actions should the nurse plan to take when obtaining the specimen

Collect a specimen upon arising in the morning

A nurse is performing suctioning for a client who has a tracheostomy. Which of the following actions should the nurse take

Pull suction catheter back 1 cm (0.5 in) if the client starts coughing

Renew the prescription for the use of restraints within 24 hours

A nurse is contributing to the plan of care for a client who is confused and requires a prescription for wrist restraints. Which of the following interventions should the nurse include in the plan of care

Remove the sleeve on the gown from the arm without the IV line

A nurse is helping my client change his hospital gown. The client has an IV infusion on if using pump. Which of the following actions should the nurse take first

I am going to listen to your abdomen

A nurse is caring for a client who is postoperative following a vaginal hysterectomy and asks for a drink. Her postoperative diet prescription reads: clear liquids, Advanced diet as tolerated. Which of the following responses should the nurse make

Start chest compression's

A nurse is caring for a patient who has a history of dysrhythmias. Upon entering the room, the nurse discovers the client is unresponsive to verbal or painful stimuli, has no respiration's, and pulse less. Which of the following actions should the nurse take first

Inability of the toddler to cry or speak

A nurse is caring for a toddler at a well child visit when the mother calls to the nurse, help! My baby is choking on his food. Which of the following findings indicate the toddler has an airway obstruction

Offer the client tart or sour foods first

A nurse is caring for an older adult client who has dysphasia following a CVA. Which of the following actions should the nurse take when assisting the client and meal time

Hold the linens away from the body and clothing.

A nurse is changing the bed linens for a client who is on bed rest. Which of the following actions should the nurse plan to take

A halo of erythema on the surrounding skin

A nurse is changing the dressings for a client recovering from an appendectomy following a ruptured appendix. The clients surgical wound is healing by secondary intention. Which of the following observations should the nurse report to the provider

Montgomery straps

A nurse is changing the dressings for a client who has two Penrose drains near an abdominal incision. Which of the following adhering devices is the best choice for the nurse to use to decrease skin irritation

Place the stool specimen collection container in a biohazard bag.

A nurse is planning to collect a stool specimen for ova and parasites from a client who has diarrhea. Which of the following actions should the nurse take when collecting the specimen

The side hip between the iliac crest and anterior iliac spine

A nurse is preparing to administer an intramuscular injection to a client who is overweight. Which of the following sites should the nurse select for the injection

Drop the eye medication into the lower conjunctival sac

A nurse is preparing to administer eye drops to a client following surgery. Which of the following actions should the nurse take when instilling the eye drops

Use a gait belt during ambulation

A nurse is preparing to assist with ambulation of an older adult client who is on bed rest for three days. Which of the following actions should the nurse take to decrease the risk of a fall

Explain the procedure to the patient

A nurse is preparing to insert an NG tube for a client who has a ballots Truxion. Which of the following actions should the nurse take first

Pinch the NG tube while removing the tube

A nurse is preparing to remove an NG tube for a client who has a partial colectomy. Which of the following actions should the nurse take

Cleanse the skin around the stoma with warm water

A nurse is reinforcing teaching with a client who has a new colostomy about proper care. Which of the following information should the nurse include in the teaching

Granulation tissue fills the wound during healing

A nurse is assisting to teach a group of unit nurses about a client who has a surgical wound that is healing by secondary intention. Which of the following information should the nurse include in teaching

face the client when speaking

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

Check to determine if the catheter tubing is kinked

A nurse is caring for a client who is postoperative and who has an indwelling urinary catheter to gravity drainage. The nurse notes no urine output in the past two hours which of the following actions should the nurse take first

Purulent

A nurse is changing the dressings for a client who is three days postoperative following a cholecystectomy. The nurse observes yellow, thick drainage on the dressing. The nurse should document this finding as which of the following types of drainage

Taut skin around the IV catheter site that is cool to the touch

A nurse is checking the IV insertion site for infiltration for a client who is receiving fluid replacement. Which of the following findings should the nurse identify as infiltration of the IV infusion site

Clamp the tubing below the collection port

A nurse is collecting a urine specimen for culture and sensitivity for a client who has a urinary tract infection. The client has an indwelling urinary catheter in place. Which of the following actions should the nurse take

What do you think caused the onset of your pain

A nurse is collecting data from a client who has an onset of severe back pain of unknown origin. Which of the following questions should the nurse asked to encourage discussion with the client

Vitamin C and zinc

A nurse is contributing to the plan of care for a client who has a wound infection following abdominal surgery. To promote healing and fight infection, which of the following vitamins and minerals should the nurse plan to increase in the clients diet

Weigh the client on arising

A nurse is contributing to the plan of care for a client who has fluid volume excess. Which of the following interventions should the nurse plan to include to monitor the clients weight

Wipes the labia minora in an anterior posterior direction

A nurse is performing a straight urinary catheterization for a female client who has urinary retention. Which of the following actions indicates the nurse is maintaining sterile technique

Use the pain scale to determine the clients pain level

A nurse is planning to administer pain medication to a client who has postoperative pain following abdominal surgery. Which of the following actions should the nurse take first

A nurse is caring for a client who has a major fecal incontinence and reports irritation at the peroneal area. Which of the following actions should the nurse take first

Check the clients perineum