Fundamentals final study guide

A nurse is assessing a client and discovers the infusion pump with the clients total preferable nutrition solution is not in fusing the nurse should monitor the client for which of the following conditions

Shakiness and diaphoresis

The nurse is assessing a client who has narcolepsy which of the following findings should the nurse expect

Sudden attacks of sleep and hallucinations at the onset of sleep

A nurse is administering nasal decongestant drops for a client which of the following actions should the nurse

Tell the client to blow her nose gently before the installation

A nurse is creating a discharge plan which of the following nursing statements indicates the nurse understands when discharge planning should be implemented

I will begin upon the clients admission to the facility

A nurse is reinforcing teaching with a client about using a transdermal patches at home which of the following statements should the nurse identify as a indication the client understands the teaching

I will clean and dry the area before applying the patch

The nurse is teaching a client who has a history of falls about Home safety which the final statements to the nurse identify as an indication of the clients understand instructions the

I will place a bath seat in my shower to use when I bathe

A nurse caring for an anti-partum client who has a deficiency anemia when teaching the class about nutrition the nurse should emphasize the need for an increase intake of which of the following foods

Red meat an organ meat

A nurse is caring for client Who has hyper natremia and requires IV fluid therapy due to his NPO status which of the following solutions to the nurse prepared to infuse for the client

.45% sodium chloride

A nurse is preparing to administer .9% sodium chloride 1000 mL IV to infuse over eight hours the nurse should set the IV pump to deliver how many milliliters per hour

125

Well auscultating clients heart sounds the nurse he was turbulence between the S1 and S2 heart sounds the nurse should document this finding is which of the following

A systolic murmur

A nurse is admitting a client who reports anorexia and Is experiencing mound nutrition which of the following laboratory findings should the nurse

Albumin

A nurse is preparing to perform hand hygiene which of the following actions should the nurse take

Apply 4 to 5 mL of liquid soap to the hands

A nurse instructed a female client about collecting a midstream urine sample which of the following clients statement indicates an understanding of the procedure

Are use the cleansing wipe from front to back

A nurse is providing teaching to a group of assistive personnel about hand hygiene which of the following statements by one of the APs indicates a need for further teaching

As long as I change clothes between clients it is not necessarily wash my hands

A nurse is caring for a client who has an indwelling urinary catheter in notes blood tinged urine in the catheter bag the nurse recognizes this finding could be a manifestation of which of the following urinary alterations

Bladder infection

A nurse is caring for a client who has a prescription for stool test for guaiac. The nurse understands the purpose of this lab tests check the stool for which of the following substances

Blood

A nurse is assessing a clients cranial nerves as part of a neurological examination which of the following actions should the nurse take to assess the cranial nerve three

Checking the pupillary response to light

A nurse is caring for a client in emergency Department who two hours earlier severed the tip of his finger in an accident during the assessment the nurse to text a strong smell of alcohol from the clients breath for which of the following findings should the nurse assess first

Date of the clients tetanus immunization

A nurse in a dialysis center is caring for a client who has a new diagnosis of end-stage kidney disease when he arrives for his first dialysis treatment he tells the nurse I decided to come today but I'm not sure if I will need to come back again this week I'm feeling much better since my discharge from the hospital and I think my kidneys are working again the nurse should identify this plant is demonstrating which of the following stages of grieving

Denial

A nurse is developing the plan of care for client who does not speak the same language is the nurse which of the following

Determine the clients level of fluency in his primary

A nurse is having difficulty caring for a client due to variables affecting the communication process which of the following should the nurse identifies an interpersonal variable

Education and gender

A nurse is planning care for client who has a decreased level of consciousness the client is receiving continuous internal feelings video gastronomy to do to an inability to swallow which of the following is the priority action by the nurse

Elevate the head of the clients bed 30 to 45°

A nurse is caring for a client who has active pulmonary tuberculosis the client requires airborne precautions and is receiving multi drug therapy which of the following precautions to the nurse take to transfer the client safely to the radiology department for a chest x-ray

Have the client wear a mask

A nurse is planning homecare for nine-year-old child following an acute exacerbation of asthma which of the following of Ericksons developmental stages to the nurse considering the planning

Industry versus inferiority

A nurse is reviewing information about the healthcare insurance Portability and accountability act with a newly licensed nurse which of the following statements by the newly licensed nurse indicates a need for further teaching

Information about a client can be this close to family members at any time

A nurse is providing preoperative teaching by demonstrating diaphragmatic breathing to a client who is scheduled for surgery in the morning which of the following actions should the nurse include in the demonstration

Inhale slowly and evenly through her nose

The nurse came for an older adult client who states I am afraid that I may fall while walking to the bathroom during the night which Of the following actions should the nurse take

Leave a night light on in the clients room

A nurse is assessing a client who has diabetes Molite us and reports foot pain the nurse should evaluate the client for which of the following alterations as indications that the client has an infection

Localized Edema and an increase in neutrophils

A nurse is inserting an IV catheter for an older adult client in preparation for an outpatient procedure which of the following veins to the nurse select

Median vein in the forearm

A nurse is teaching a class of older students about the expected psychological changes of aging which of the following changes to the nurse include in the discussion

More difficulty seeing due to greater sensitivity to glare, decreased cough reflex and decreased bladder capacity

A newly licensed nurse is applying prescribed wrist restraints and a client which is applying actions should the nurse take

Secure the restraints using a quick release tie

A nurse is caring for a client who has peripheral vascular disease and reports difficulty sleeping because of cold feet which of the following actions should the nurse take promote the clients comfort

Obtain a pair of slippers or socks for the client

A nurse in a long-term care facility is observing assistive personnel changing room for a client who has fecal incontinence which of the following actions indicate the AP understand the principle of infection control

Places the linen that touched the floor in the soiled linen bag

A nurse is assessing a client spell sound at which of the following points is the assessment should the nurse auscultate the abdomen

Prior to percussing the abdomen

A nurse is caring for a client who needs a stool specimen collection which of the following actions should the nurse take one obtaining the specimen

Send the specimen immediately to the lab

The nurse is preparing a client for outpatient surgery after the nurse inserts IV catheter the client reports pain in the incision area which of the following actions should the nurse take

Remove the catheter and insert another into a different site

A nurse is working with assistive personnel while caring for a surgical client was one day post operative which of the following should the nurse take responsibility for completing

Removing the abdominal dressing

A nurse is assessing a client who is experiencing prosthetic hypertrophy which of the following findings associate with urinary retention with the nurse expect

Report a feeling pressure Tenderness over the symphysis pubis Distended bladder Voiding 30 mL frequently

A nurse find an open file of morphine lying on top of the cabinet and the clients room which of the following actions should the nurse

Report the discrepancy immediately

A nurse is giving a presentation about client confidentiality to a group of newly licensed nurses which of the following actions is an example of a violation of confidentiality

Reporting laboratory findings to a member of the clients family

A nurse is developing a plan of care for client who practices Islam which of the following actions should the nurse include in the plan

Request meal tray without pork

A nurse is caring for four clients who have drainage tubes which of the following client should the nurse recognizes being at risk for hypokalemia

The client who has a nasogastric tube to suction

A nurse is assessing a client cardiovascular system to palpate for an expected pulsations in the Pulmonic area at which anatomical location to the nurse place your fingers

The left second intercostal space

A nurse is caring for a client who is finally getting out of bed and states I'm OK I guess I should have called for help to the bathroom after assessing the client the nurse notified the provider which is fine documentation should the nurse include in the clients medical record

The provider was notified

A nurse is caring for an eight month old infant who screams when the Parent leaves the room the parent begins to crisis I don't understand why my child is so upset I've never seen my child act this way around others before which of the following statements to the nurse make

This is a normal expected reaction for a child at this age

A nurse is orienting a newly licensed nurse about documentation of a clients formation in the electronica health record which of the following statements by the newly licensed nurse identifies understanding the purpose of documentation

Documentation as a communication tool for the interprofessional healthcare

A nurse is reviewing a clients prescription for 1000 mL of 5% dextrose in water I need to infuse over eight hours at 1400 the nurse observes that there is 500 mL of solution remaining in the clients IV bag at what time should the nurse administer the next bag of solution

1800

A nurse in the emergency department is preparing to administer naloxone .4 mg IV bolus to a client who has opioid induced respiratory depression available is in lockdown injection .2 mg/mL how many milliliters in the nurse administer per dose

2

The nurse is caring for a client who has an NG tube the nurse test the pH of the secretions to determine if the tubes correctly placed which of the following readings to the nurse expect

4.0

The charge nurse is anticipating the mission of four clients and planning the room assignments which of the following Client should the nurse assigned to the room closest to the nurses station

A client who sustained a head injury and is having periods of confusion

A nurse is rehearsing assertive communication approaches to use when declining leader ship of the nursing department committee which of the following statements to the nurse make

I declined the opportunity at this time

A nurse is assessing a client who has received crutches in an urgent care center following a foot injury which of the following statements should the nurse and identify as an indication that the client needs further teaching

I have a set of my brothers crutches in my basement I can also use

A nurse is working on an orthopedic unit is caring for four clients which of the following clients to the nurse identifies as being at greatest risk for skin breakdown

An older adult who has a hip fracture in his in bucks traction

A nurse is caring for a client who has a new diagnosis of chronic kidney disease which of the following statements to the nurse identify as an indication of antipatory rieving

I just can't believe the dialysis is going to ruin my whole life

A nurse is receiving change of shift report for a group of assigned clients the nurse anticipate which of the following activities first and delivering client care using the nursing process

Collect and organize client data

A nurse is instructing a young adult client about health full sleep habits which of the following statements to the nurse identify it as an indication the client needs

I watch television until I fall asleep at night

A nurse is teaching an assistive personnel about using personal protective equipment while caring for clients which of the following statements to the nurse identify as an indication the AP understands the instruction

I will Wear gloves and a gown when bathing a client who has open skin lesions

A nurse is caring for a client who has a mental disorder order the client asked about the medications in there affects the nurse asked the client why he needs to know this which of the following non-therapeutic communication techniques as the nurse

Asking for an explanation

A nurse is assessing a client radio pulse in terms of the pulse is regular which of the following actions should the nurse

Assess the apical pulse for a full minute

The client receives the wrong medication the nurse who made the medication error should take which the following actions

Assess the client

A nurse in the clinic is interviewing a client who will undergo diagnostic testing the nurse should ask about clients potential allergies during which the phases of the nursing process

Assessment

A nurse is implementing direct nursing care for a group of clients in acute care facility which of the following actions by the nurse is considered an indirect nursing care activity

Assigning tasks to an assistive personnel

A nurse is caring for a client who experienced a lacerated spleen has been on bed rest for several days the nurse auscultates decreased breath sounds in the lower lobes of both lungs the nurse should realize that the sign is most likely an indication of which of the following conditions

Atelectasis

In assistive personnel reports of clients vital signs assessed panic temperature 98.8 pulse 92 bpm respiratory rate 18 bpm and blood pressure of 98/58 mg which of the following vital signs for the nurse remeasure

Blood pressure

A nurse on a medical unit is caring for a client who suddenly becomes confused and drowsy additional data includes pulse 100 bpm respiratory rate 24 bpm blood pressure 132/76 mg in temperature of 98.2° which of the following actions should the nurse perform

Complete a neurological check

A family of an older adult client brings him to the emergency department after finding him wandering outside during the initial assessment the nurse notes to the client flinches when she palpated his abdomen it response to questions only by nodding and smiling which of the following factors to the nurse identify as a likely explanation for the clients behavior

Confusion

The nurse is assessing for sinuses and the client was dark skin which of the following sites should the nurse use to identify sinuses in the client

Conjunctiva

A nurse is discussing the norming stage of the group development process for the student nurse which of the following statements by the student indicates understanding of the discussion

Consensus evolves in the stage

The nurses working with a team of nursing personnel within a facility which of the following are necessary tasks performed rules that members of the group or the leader must perform

Coordination evaluator and energizer

A nurse is caring for a client request Prescription pain medications which of the following actions should the nurse perform first

Determine the location of the pain

A nurse is caring for a client who refuses treatment asked to be discharged from the hospital against medical advice the nurse notifies the clients provider who tells the nurse to restrain the client if necessary to keep her from leaving the hospital the nurse understands the restraining the client would be considered which type of civil action by the nurse

False imprisonment

The nurse is caring for a client who has impaired mobility which of the following support device is should the nurse plan to use to prevent client from developing plantar flexion contractions

Footboard

A nurse is teaching a client about carbon monoxide poisoning which of the following statements to the nurse Identify as an indication that the client needs further instruction

I can detect the presence of carbon monoxide by metallic odor

A nurse in the clinic is teaching a group of clients about preventing low back pain and injury which of the following statements to the nurse identifies an indication that the client requires further clarification

I will sit with my knees lower than my hips

A nurse is instructing a client who has a new diagnosis of Raynaud's disease about preventing the onset of manifestations which of the following clients statement should indicate to the nurse the need for additional teaching

I will take my medications at the first sign of an attack

A nurse is providing teaching to an assistive personnel about caring for clients with their strengths which of the following assessments by the AP indicated and understanding of the teaching

I will tie restraint the portion of the bed that moves from the head of the bed is

A nurse is providing discharge teaching for a client requires home oxygen therapy which of the following statements the nurse identifies an indication the client needs further

I will wear synthetic clothing and wool socks when using my oxygen

A nurse is discharging a client who came in outpatient clinic with an ankle sprain which of the following statements to the nurse identify as an indication the client understands the discharge instructions

I'll apply ice to my ankle today and tomorrow

A nurse is caring for several clients who are at various developmental stages the nurse should explain that according to Ericsson acceptance of death is a primary task of which of the following stages of psychological development

Integrity versus

The nurse receives a client care assignment from the charge nurse that he believes is unfair the nurse voice his concern to charge Nurse the nurse is using which level of communication at the time

Interpersonal

A nurse is instructing client in the community about relationship development the nurse should explain that according to Ericsson establishing relationships with committed is a primary task which of the five stages of psychological

Intimacy versus

A nurse is talking with a client who's about to start using transcutaneous electrical nerve stimulation to manage chronic pain which of the following statements to the nurse identifies indication the client needs further teaching

It's unfortunate that I have to be in the hospital for this treatment

A nurse is assessing an older adult client who has osteoporosis which of the following spinal deformity should the nurse expect to find the client

Kyphosis

The nurse is appearing to obtain a blood specimen from a client by venipuncture the client is receiving IV fluids through an IV catheter inserted in the Pacific main of the right forearm which of the following sites for the nurse plan to use obtain a blood specimen

Left forearm

A nurse is assisting with transferring a client from the bed to wheelchair which of the following actions should the nurse take

Lock the wheels of the bed in the wheelchair

A nurse accidentally administers the wrong medication to a client which Results in a severe allergic reaction and prolong is the clients hospitalization the client should rightfully sue the nurse for which of the following

Malpractice

A nurse is caring for a client requires isolation for active pulmonary tuberculosis which of the following precautions should be included when creating a signed poster outside the

Mask, sign on the door, sharps container and wash your hands

A nurse is measuring a client for knee high anti-embolic stockings to help prevent being a stasis which of the following actions should the nurse take

Measure from the heel to the popliteal space

A nurse is caring for an older adult client who was alert and oriented admission but now seems increasingly restless and intermediately confused which is a flying action should the nurse take to address the client safety needs

Move the client to a room closer to the nurses station

A client smoking in his bathroom has dropped a cigarette butt in it to a wastepaper basket which begins to smolder which of the actions is the nurses priority

Moved any clients in the immediate vicinity

A nurse is complaining of clients history and physical examination which of the following information to the nurse consider subjective data

Nausea

A nurse is providing care to client who is on strict bed rest following surgery the nurse assist the patient to the bedside commode in the client to stains injury to the operative area which of the following types of torts has the nurse

Negligence

A nurse is caring for a client who states I have got to get out of this hospital they have found my address and are coming for my family the nurses friends don't worry no more harm your family which of the following types of communication breakdown is the response represent

Offering false reassurance

A nurse is preparing a sterile field which of the following actions should the nurse identify is contaminating the field

Opening a sterile package over the middle of the sterile field

A nurse is completing discharge teaching with the client which of the following barriers to learning the nurse identifies with the client which should the nurse interpret as a need to postpone the session

Paine

A nurse is completing his admission assessment on an adolescent client who is a vegetarian heat milk products but does not like beans which of the following items to the nurse suggest the client order for lunch to buy the nutrients most likely to be lacking in his diet

Peanut butter and jelly sandwich

The nurses attending a social event when another guest cops weekly ones graphs his throat with his hands and cannot talk which of the following actions should the nurse take

Perform the Heimlich maneuver

A nurse is preparing to administer three liquid medications to a client who has an NG tube with intermittent section which of the following actions should the nurse take

Pinched the tube prior to attaching the medication syringe

A nurse is caring for a client who has had an allergic hematopoietic stem cell transplant which of the following infection control precautions to the nurse take when caring for the client

Protective

A nurse is caring for a client who is discussing his post Trumatic stress disorder and states everyone thinks you should be able to put it out of your mind it happened so long ago just got over at the nurse response must be very frustrating to encounter this kind of attitude the nurses using which kind of communication technique

Reflection

A nurse is discussing indications for urinary catheterization with a newly licensed nurse which of the following indications to the nurse include

Relief of urinary retention

A nurse in a long-term care facility is planning care for several clients which of the following activities to the nurse delegator the license practical

Scheduling a diagnostic test for client

A nurse is performing tracheostomy care for client and suctioning to remove copious secretions Which of the following actions should the nurse

Section 2 to 3 times the 60 second pause between passes

A nurse is working with a licensed practical nurse to care for a client who is receiving a continuous IV fusion which of the following findings reported by the LPN indicates to the nurse or the client has phlebitis at the IV insertion site

The area surrounding the insertion site feels warm to the touch

A nurse is assessing a client at a follow up clinic visit for acute lower back pain a goal for this client is to use proper body mechanics at all times which of the following findings indicate that the client is meeting this goal

The client base is the direction of movement was sliding an object across the floor

A nurse is caring for a client who is post operative the nurse should base her pain management interventions primarily on which of the following methods of determining the intensity of the clients pain

The client self reports of pain severity

A nurse is providing oral care for a client who is immobile which of the following actions should the nurse take

Turn the client on his side before starting oral care

A nurse is preparing to remove a client who is only partially able to assist up in bed which of the following message to the nurse use

Two nurses using a friction reducing device

A nurse is planning care for an older adult client who is at risk for developing pressure ulcers which of the following intervention should the nurse used to maintain the integrity of the client skin

Use a transfer device to lift the client up in bed

A nurse administers an incorrect medication to a client following an assessment of the client the nurse determines the client has experienced no untoward effects as a result of the medication the nurse does not complete an incident report because no harm came to the client which of the following ethical principles to the nurse violate

Veracity

A nurse is reviewing laboratory results of a client who has a pressure ulcer the nurse should identify an elevation in which of the following laboratory values as an indication the client has developed an infection

WBC

A nurse is orienting a new assistive personnel to the unit for which of the following actions should the nurse intervene

Washes and ranch is her hands for 10 seconds

The home health nurse is conducting a home safety assessment for an older adult client which of the following findings should the nurse identify as a safety risk

Water heater temperature 54.4°C and throw rugs

A nurse is planning care for the client requires airborne cautions which of the following actions should the

We're an N 95 respirator mask

A nurse is admitting a client from a long-term care facility the nurse should use close ended questions when assessing which of the following factors

When asking If the client took his medications this morning

A nurse at an extended care facility is instructing a class of assistive personnel about client use of assistive devices during ambulation which of the following instructions to the nurse give the APs about the clients use of a cane

When the client moves he should move the cane forward with it

A nurse enters an older adult client room to enter a saline lock the client asked the nurse why do I need that I am drinking plenty of fluids which of the following responses to the nurse provide

Your provider has prescribed antibiotic therapy to be administered intravenously every six hours

A nurse is administering a cold therapy application to a client which of the following manifestations should the nurse identify as an indication for discontinuing the application due to systemic response

shivering