Fundamentals A

The nurse identifies which change in the genitourinary system is usually associated with client aging?

Increased frequency

While the client is being treated for a wound infection. It is important for the nurse to routinely perform which action?

Check and record the clients temperature

The nurse identifies a staff member is using standard precaution appropriately if which action is observed?

The staff member place is contaminated linens in a leak proof bag.

The nurse obtains a health history from an older adult client. Which statement does the nurse expect the client to make

"I think that I am a little shorter than I used to be"

The clinic nurse interviews a male age adult client who comes to the clinic reporting difficulty sleeping and ongoing fatigue. The nurse learns that the client works at security guard and frequently works the night shift. Which is the best initial statement for the nurse to make while discussing the clients problem?

"Tell me about your usual sleeping habits."

The nurse cares for a client beginning intermittent heparin therapy. The nurse knows which laboratory test is used to monitor effectiveness of heparin?

Activated partial thromboplastin time

Following a total hip arthroplasty, the older adult client is prescribed to start ambulation using a walker. Which statement by the nurse regarding ambulation is best?

Advance the walker first, then carefully walk forward

A middle-age adult client is admitted to the hospital for hematuria. The client has no previous history of illnesses, is married, and has three children in high school. Which task of middle adulthood is most likely to be disturbed by physical disability?

Assisting the children to grow to adulthood.

The nurse teaches correct body mechanics to the unlicensed assistive personnel. Which suggestion by the nurse is most appropriate?

Bend when lifting objects.

The nurse provides care for a client at risk for developing a pressure injury. The nurse knows which factors puts the client at risk? (Select all that apply)

Bony prominence. In mobility. Low serum albumin.

The nurse explains to the nursing student that a client has a new diagnosis of psoriasis. Which best described psoriasis?

Chronic autoimmune reaction

The client is experiencing an episode of acute pain. Which physiological change should the nurse expect to occur when the client is experiences acute pain?

Decreased skin temperature.

After administering pain medication to a client, it is most important for the nurse to take which action?

Determine whether the medication is effective

On the morning before surgery, a client signs and operation consent form. Soon afterwards, the client called the nurse and states I do not want the surgery. Which action does the nurse take first?

Encourage the client to discuss reasons for canceling the surgery

The nurse is preparing a client for surgery. What is the nurses responsibility regarding informed consent for the surgery?

Ensuring the consent form is signed and attached to the clients record.

A nurse provides teaching a modifiable risk factors related to the cardiovascular system. Which factor does the nurse include in the teaching? (Select all that apply)

High cholesterol levels. Elevated blood pressure. Cigarette smoking. Diet higher in sugar and fats.

The nurse prepares for a urinary catheterization procedure for a client. Which action by the nurse is most important?

Keeps the field holding the supplies in front of the nurse

The nurse does discharge teachings with the client that has a new diagnosis of eczema. Which common food are likely contributing factors of eczema that the client should eliminate in the diet?

Milk, wheat, egg whites.

The nurse provides care for a client with a body mass index ( BMI) of 37.0 kg which is the best description of the clients body weight?

Obese

The nurse cares for a client with an abdominal wound. The nurse notes there's purple to drainage from the wound. Which action does the nurse take first?

Places the client on contact precaution

Which nursing action does the nurse have to establish the first when caring for a client in pain?

Stabley should a trusting relationship with a client

The nurse prepares a client for discharge. The client tells another staff member "That nurse really doesn't care about me and I don't want to talk anymore". Which interpretation of the clients statement by the nurse is best?

The client has a common response to the end of the nurses relationship.

The nurse provides care for a client in a long-term care facility. Which client indicates a need for the nurse to reinforce teaching about the use of assistive devices? (Select all that apply)

The client places the weight on the axilla when taking a step using crutches. The client place is a cane in the hand on the side of the unaffected leg. The client uses a four-point crutch gait with the weight bearing on the affected leg

A liver scan is prescribed for a client prior to surgery. Which description best describes the procedure?

The client will be asked to life still while a scanning probe is passed back-and-forth over the body.

The nurse evaluates the laboratory results of several clients. For which client with the nurse expect a decrease in serum albumin?

The client with severe liver disease

Moist to dry dressing changes are prescribed for a client. After the first layer of dressing is removed, the client yell at the nurse, "ouch, that really hurts. Are you sure you're doing it right?" Which statement is the best response by the nurse

"I'm sorry this hurts. I will add some normal saline to loosen it a bit more"

Which nursing action is best to identify and manage a clients valuable items during hospitalization?

Document the disposition of the clients valuable items in the medical record

I discharge, the nurse advice is the client about a calorie restricted diet. Which information does the nurse include?

Losing 1 to 2 pounds per week is safe and effective.

The nurse provides care for an older client with a diagnosis of constipation. The nurse understands which factor contributes to the development of constipation in the older adult? (select all that apply)

Older adults clients may eat a diet with inadequate fluid and bolt. Older adults experience slow peristalsis and decrease muscle tone. Older adults make nor the sensation to defecate. Older adults are typically more sedentary and less likely to exercise.

A client diagnosed with ovarian cancer experiences severe pain. Which principle does the nurse remember when caring for the client?

Pain medication is more effective if given before pain becomes severe.