fundamentals 2 skills
nurse caring for client who is postoperative following vaginal hysterectomy and asks for drink. Her postoperative diet prescription reads: clear liquids; advance diet as tolerated. Which of following responses should nurse make?
"I am going to listen to your abdomen."
nurse assessing client who has an onset of severe back pain of unknown origin. Which of following questions should nurse ask to encourage discussion with client?
"What do you think caused onset of your pain?"
nurse changing dressings for client recovering from an appendectomy following ruptured appendix. Client's surgical wound healing by secondary intention. Which of following observations should nurse report to provider?
A halo of erythema on surrounding skin
nurse changing bed linen for client who is on bed rest. Which of following actions should nurse plan to take?
Hold linens away from body & clothing
nurse caring for client who has major fecal incontinence & reports irritation in perianal area. Which of following actions should nurse take first?
Check client's perineum
nurse caring for client who postoperative & who has an indwelling urinary catheter to gravity drainage. Nurse notes no urine output in past 2 hr. Which of following actions should nurse take first?
Check to determine if catheter tubing kinked
nurse collecting urine specimen for culture & sensitivity for client who has urinary tract infection. Client has an indwelling urinary catheter in place. Which of following actions should nurse take?
Clamp tubing below collection port
nurse providing teaching to client who has new colostomy about proper care. Which of following information should nurse include in teaching?
Cleanse skin around stoma with warm water
nurse caring for client who had mastectomy & has self-suction drainage evacuator in place. Which of following actions should nurse take to ensure proper operation of device?
Collapse device of air after emptying
nurse planning care for client who has prescription for collection of sputum specimen for culture & sensitivity. Which of following actions should nurse take when obtaining specimen?
Collection specimen upon arising in morning
nurse assisting client who is eating at mealtime. Client grabs her neck with both hands & appears frightened. Which of following actions should nurse take first?
Determine whether client is able to breathe
nurse replacing surgical dressing on client who had abdominal surgery. Which of following actions should nurse take?
Don clean gloves to remove old dressing
nurse preparing to administer eye drops to client following surgery. Which of following actions should nurse take when instilling eye drops?
Drop eye medication in outer third of the lower conjunctival sac
nurse caring for client who has an NG tube for intermittent enteral feedings. Which of following actions should nurse take?
Elevate client's head of bed 45 degree before feeding
nurse performing eye irrigation for client who was exposed to smoke & ash. Which of following actions should nurse take?
Exert pressure on bony prominences when holding eyelids open
nurse preparing to insert an NG tube for client who has a bowel obstruction. Which of following actions should nurse take first?
Explain procedure to client
nurse caring for client who has hearing impairment. Which of following interventions should nurse use when speaking with client?
Face client when speaking
nurse providing teaching to group of unit nurses about wound healing by secondary intention. Which of following information should nurse include in teaching?
Granulation tissue fills the wound during healing
nurse caring for toddler at well-child visit when mother calls to nurse, "Help! My baby choking on his food." Which of following findings indicates toddler has an airway obstruction?
Inability of toddler to cry or speak
nurse administering cleansing enema to client who is scheduled for diagnostic procedure. Which of following actions should nurse take?
Insert tip of tubing 8 cm (3.1 in)
nurse preparing to anchor with tape catheter tube for male client who has newly inserted indwelling urinary catheter. At which of following locations should nurse tape catheter?
Lower abdomen
nurse changing dressings for client who has two Penrose drains near an abdominal incision. Which of following adhering devices best choice for nurse to use decrease skin irritation?
Montgomery straps
nurse is caring for an older adult client who has dysphagia following cerebrovascular accident. Which of following actions should nurse take when assisting client at mealtime?
Offer client tart or sour foods first
nurse preparing to remove an NG tube for client who has partial colectomy. Which of following actions should nurse take?
Pinch NG tube while removing tube
nurse planning to collect stool specimen for ova & parasites from client who has diarrhea. Which of following actions should nurse take when collection specimen?
Place stool specimen collection container in biohazard bag
nurse performing suctioning for a client who has tracheostomy. Which of following actions should nurse take?
Pull suction catheter back 1 cm (0.5 in) if client starts coughing
nurse changing dressings for client who is 3 days postoperative following cholecystectomy. Nurse observes yellow, thick drainage on dressing. Nurse should document this finding as which of following types of drainage?
Purulent exudate
nurse helping a client change his hospital gown. client has an IV infusion on an IV pump. Which of following actions should nurse take first?
Remove sleeve of gown from arm without IV line
nurse planning care for client who is confused & requires prescription for wrist restraints. Which of following interventions should nurse include in plan of care?
Renew prescription for use of restrains within 24 hr
nurse caring for client who has history of dysrhythmias. Upon entering room, nurse discovers client unresponsive to verbal or painful stimuli, has no respiration, & is pulseless. Which of following actions should nurse take first?
Start chest compressions
nurse caring for client who is receiving an IV fluid replacement. Which of following findings should nurse identify as infiltration of IV infusion site?
Taut skin around IV catheter site that is cool to touch
nurse applying antiembolitic stocking for client who has history of deep vein thrombosis. Which of following actions should nurse take when applying stockings?
Turn stocking inside out up heel before applying
nurse preparing to assist with ambulation of an older adult client who was on bed rest for 3 days. Which of following actions should nurse take to decrease risk of fall?
Use a gait belt during ambulation
nurse planning to administer pain medication to client who has pain following abdominal surgery. Which of following actions should nurse take first?
Use pain scale to determine client's pain level
nurse planning care for client who has wound infection following abdominal surgery. To promote healing and fight infection, which of following vitamins & minerals should nurse plan to increase in client's diet?
Vitamin C and zinc
nurse planning care for an adult client who has fluid volume excess. Which of following interventions should nurse plan to include to monitor client's weight?
Weigh client on arising
nurse performing straight urinary catheterization for female client who has urinary retention. Which of following actions indicates nurse maintaining sterile technique?
Wipes labia minora in an anteroposterior direction
nurse planning care for group of clients who are receiving oxygen therapy. Which of following clients should nurse plan to see first?
client who has heart failure & is receiving 100% oxygen via partial rebreather mask
nurse preparing to administer an intramuscular injection to client who is overweight. Which of following sites should nurse select for injection?
side hip between iliac crest & anterior iliac spine
nurse teaching client who is recovering from gallbladder surgery how to use an incentive spirometer. Which of following information should nurse include in teaching?
Hold breath for 5 seconds after goal volume is reached