Fundamentals Assessment B

nurse is preparing to administer 750 mL of 0.9% sodium chloride IV to infuse over 7 hr. The nurse should set the infusion pump to deliver how many mL/hr?

107

nurse working in the emergency department is witnessing the signing of informed consent forms for the treatment of multiple clients during her shift. Which of the following individuals' signatures may the nurse legally witness?

16, 22, 8, 17

nurse is giving a change-of-shift report about a client he admitted earlier that day who has pneumonia. Which of the following pieces of information is the priority for the nurse to provide?

Breath

A nurse is caring for a client who does not speak the same language as the nurse. When working with the client through an interpreter, which of the following actions should the nurse take?

Speak directly to the patient

Best source of protein

cheddar cheese

nurse is planning care for a client who has fluid overload. Which of the following actions should the nurse plan to take first?

evaluate electrolytes

nurse is caring for a child who has a prescription for a blood transfusion. The parents have refused the treatment due to religious beliefs. Which of the following actions should the nurse take?

examine personal values

A nurse is preparing to administer enoxaparin subcutaneously to a client. Which of the following actions should the nurse take?

45 angle

nurse is calculating a client's fluid intake over the past 8 hr. Which of the following items should the nurse plan to document on the client's intake and output record as 120 mL of fluid?

8 oz ice chips

A nurse is providing home care for a client who is receiving tube feedings and medication through a gastrostomy tube. The family member providing the feedings reports that the client has begun to have diarrhea. For which of the following practices should the nurse intervene?

Cleanse the bag every 24 hours

nurse is caring for a client who has a sodium level of 125 mEq/L. Which of the following findings should the nurse expect?

abd. cramping

nurse is reviewing the medical records of a client who has a pressure ulcer. Which of the following findings should the nurse expect?

albumin lvl 3

nurse is performing a skin assessment of a client who has a lesion on his anterior thigh and expresses concern about skin cancer. Which of the following findings should the nurse report to the provider as a possible indication of a skin malignancy?

an uneven shape

nurse is planning care for a client who has had a stroke, resulting in aphasia and dysphagia. Which of the following tasks should the nurse assign to an assistive personnel

assis client w/partial bed bath, measure BP, communication board

A home health nurse who has attended a training session for the therapeutic use of aromatherapy with essential oils is planning to use this modality with some of her clients. For which of the following clients should the nurse consult the provider before using this complementary therapy?

asthma

nurse is caring for a client who has an aggressive form of prostate cancer. The provider briefly discusses treatment options and leaves the client's room. When the nurse asks if the client would like to discuss any concerns, the client declines. Which of the following statements should the nurse make?

available to talk if you

nurse is teaching a client about dietary management of hypercholesterolemia. Which of the following foods should the nurse suggest that the client add to his diet?

avocados

nurse is caring for a client who has an indwelling urinary catheter. Which of the following assessment findings indicates that the catheter requires irrigation?

bladder scan shows 525 ml

nurse is completing an admission assessment of an older adult client. Which of the following findings should the nurse identify as a potential indication of abuse?

bruises

nurse is caring for a group of clients on a medical-surgical unit. In which of the following situations does the nurse demonstrate the ethical principle of veracity?

cancer diagnosis affirmatively

nurse receives report about a client who has 0.9% sodium chloride infusing IV at 125 mL/hr. When the nurse performs the initial assessment, he notes that the client has received only 80 mL over the last 2 hr. Which of the following actions should the nurse take first?

check IV tubing

nurse is providing discharge teaching to a client who has a new prescription for a home oxygen concentrator. Which of the following instructions should the nurse provide to the client and his family? (Select all that apply.)

check the cord, purchase a generator

nurse has an order to remove sutures from a client. After retrieving the suture remover kit and applying sterile gloves, which of the following actions should the nurse take next?

clean sutures along the incision site

nurse on a medical unit is preparing to discharge a client to home. Which of the following actions should the nurse take as part of the medication reconciliation process?

compare prescriptions w/ meds

A nurse is teaching a client and his family how to care for the client's tracheostomy at home. Which of the following instructions should the nurse include in the teaching?

cover when outside

nurse is administering 1 L of 0.9% sodium chloride to a client who is postoperative and has fluid-volume deficit. Which of the following changes should the nurse identify as an indication that the treatment was successful?

decrease HR

nurse in a provider's office is obtaining the health and medication history of a client who has a respiratory infection. The client tells the nurse that she is not aware of any allergies, but that she did develop a rash the last time she was taking an antibiotic. Which of the following information should the nurse give the client?

document exact medication you were taking

nurse is caring for a client who has pharyngeal diphtheria. Which of the following types of transmission precautions should the nurse initiate?

droplet

nurse is admitting a client who is having an exacerbation of heart failure. In planning this client's care, when should the nurse initiate discharge planning?

during the admission

client who is nonambulatory notifies the nurse that his trash can is on fire. After the nurse confirms the fire, which of the following actions should the nurse take next?

evacuate the client

nurse enters a client's room and finds her on the floor. The client's roommate reports that the client was trying to get out of bed and fell over the bedrail onto the floor. Which of the following statements should the nurse document about this incident?

found on floor

nurse is caring for a client who has a respiratory infection. Which of the following techniques should the nurse use when performing nasotracheal suctioning for the client?

intermittent suction

nurse is assessing a client who reports increased pain following physical therapy. Which of the following questions should the nurse ask when assessing the quality of the client's pain?

is your pain sharp or dull

nurse is initiating a protective environment for a client who has had an allogeneic stem cell transplant. Which of the following precautions should the nurse plan for this client?

make sure the client wears a mask

Best pain management

might help me to listen to music while i'm lying in bed

nurse is caring for a group of clients. Which of the following actions should the nurse take to prevent the spread of infection?

negative-pressure airflow

nurse is auscultating the anterior chest of a client newly admitted to a medical-surgical unit.

normal BS

nurse is caring for a client who is postoperative and has signs of hemorrhagic shock. When the nurse notifies the surgeon, he directs her to continue to measure the client's vital signs every 15 min and call him back in 1 hr. From a legal perspective, which of the following actions should the nurse take next?

notify nurse manager

charge nurse is observing a newly licensed nurse prepare a sterile field. Which of the following actions should the charge nurse identify as contaminating the sterile field?

opens on wet surface

nurse is preparing to transfer a client who can bear weight on one leg from the bed to a chair. After securing a safe environment, which of the following actions should the nurse take next?

orthostatic HTN

nurse on a medical-surgical unit is caring for a client who has a new prescription for wrist restraints. Which of the following actions should the nurse take?

pad the client's wrist before

nurse is caring for a client who is postoperative. When the nurse prepares to change her dressing, she says, "Every time you change my bandage, it hurts so much." Which of the following interventions is the nurse's priority action?

pain meds

A middle adult client tells the nurse, "I feel so useless now that my children do not need me anymore." Which of the following responses should the nurse make?

people in middle adulthood

nurse is planning teaching for a group of adolescents who each recently had surgical placement of an ostomy. Which of the following methods should the nurse use as a psychomotor approach to learning?

practice

A nurse is reviewing evidence-based practice principles about administration of oxygen therapy with a newly licensed nurse. Which of the following actions should the nurse include?

regulate oxygen

Behind-the-ear-hearing aid

remove before shower

nurse is caring for a client who has a heart murmur. The nurse is preparing to auscultate the pulmonary valve. Over which of the following locations should the nurse place the bell of the stethoscope?

second intercostal space

nurse is preparing to insert an IV catheter into a client's arm prior to initiating IV fluid therapy. Which of the following interventions should the nurse implement to prevent infection?

thread the iv

A nurse is caring for a client who is postoperative following knee arthroplasty and requires the use of a thigh-length sequential compression device. Which of the following actions should the nurse take?

two fingers under the sleeve

nurse is caring for a client who has diarrhea due to shigella. Which of the following precautions should the nurse take?

wash her hands before and after

nurse is caring for a client who has a terminal diagnosis and whose health is declining. The client requests information about advance directives. Which of the following responses should the nurse make?

we can talk about advance directives, and I can also give you some brochures about them."

nurse is educating a client who has a terminal illness about her request to decline resuscitation in her living will. The client asks what would happen if she arrived at the emergency department and had difficulty breathing. Which of the following responses should the nurse provide?

we will apply ox thru a tube in your nose

nurse is teaching a client whose left leg is in a cast about using crutches. Which of the following statements should the nurse identify as an indication that the client understands the teaching?

when descending the stairs, i will first shift my weight

nurse is planning to initiate IV therapy for an older adult client who requires IV fluids. Which of the following actions should the nurse take?

without tourniquet

nurse is admitting a client who has been having frequent tonic-clonic seizures. Which of the following actions should the nurse add to the client's plan of care?

wrap blankets

nurse has just inserted an NG tube for a client. Which of the following assessment findings should the nurse expect to confirm correct tube placement?

x ray