Fundamentals midterm
A nurse is preparing to administer levothyroxine 50 mcg PO to a client. How many milligrams (mg) should the nurse plan to administer? -0.05 mg -500 mg -0.5 mg -50 mg
.05 mg
A nurse is receiving report on a group of clients. Using the ABCDE priority framework, which of the following clients should the nurse see first? -A client who has pneumonia and has developed wheezing. -A client who has early dementia and awoke confused to their location this morning. -A client who is scheduled for discharge and has a 38.4° C (101.1° F) temperature this morning. -A client who is postoperative and has a urine output of 50 mL for the past 3 hr
A client who has pneumonia and has developed wheezing.
A nurse is caring for a group of clients. Which of the following clients should the nurse identify is at highest risk for developing a pressure injury? -A client who makes frequent slight changes in position and walks occasionally. -A client who is receiving enteral feeding and can change position independently. -A client who is unresponsive to verbal commands and changes position occasionally. -A client who alert and responsive and eats 25% of each meal.
A client who is unresponsive to verbal commands and changes position occasionally.
A nurse is teaching a newly licensed nurse about a nonrebreather oxygen mask. Which of the following instructions should the nurse include? -The reservoir bag on a nonrebreather mask should collapse with exhalation. -Use a nonrebreather mask to deliver low-flow oxygen. -A nonrebreather mask dries a client's mucous membranes. -A nonrebreather mask should fit snugly over a client's face.
A nonrebreather mask should fit snugly over a client's face.
A charge nurse is teaching a newly licensed nurse about accessing a client's medical records. Which of the following should the nurse include? -A nurse can only access the records of clients they are actively caring for. -A nurse can share information about a client with clients who have a similar diagnosis. -A nurse can access the records of any client in the healthcare facility, as long as the information is not shared. -A nurse can only share information from the client's medical record with immediate family members.
A nurse can only access the records of clients they are actively caring for.
A nurse is preparing to obtain an electronic blood pressure measurement on a client. Which of the following actions should the nurse plan to take? -Place the blood pressure cuff 5 cm (2 in) above the client's antecubital space. -Select a cuff that covers 50% of the client's upper arm. -Align the artery indicator on the blood pressure cuff with the client's brachial artery. -Elevate the client's arm above the level of the heart.
Align the artery indicator on the blood pressure cuff with the client's brachial artery.
A nurse is providing teaching to a newly licensed nurse about the purpose of documentation in the client's health record. Which of the following information should the nurse include? -Grants billing to review client care provided -Authorizes providers to co-sign on nurses' notes -Allows nurses to document for other nurses on client care -Allows health care team members to document client care
Allows health care team members to document client care
A nurse is caring for a client who has dysphagia. Which of the following actions should the nurse take? -Elevate the client's head of the bed to 45° during meals. -Instruct the client to tilt their head back while swallowing. -Alternate the client's liquids and solids during meals. -Turn on the client's television during meals.
Alternate the client's liquids and solids during meals
A nurse is designing a poster presentation for staff nurses about therapeutic communication. Which of the following techniques should the nurse include? -Offering sympathy -Offering approval or disapproval -Asking for explanations -Asking open-ended questions
Asking open-ended questions
A nurse is discussing types of communication styles with a group of staff nurses. Which of the following information should the nurse include? -Assertive communicators communicate resentment in secretive ways. -Assertive communicators are confident in their communications. -Passive communicators communicate clearly and honestly. -Passive communicators become hostile when they are challenged.
Assertive communicators are confident in their communications.
A nurse is actively listening to a client who has concerns about a new diagnosis. Which of the following categories of Swanson's Theory of Caring is the nurse demonstrating? -Doing for -Being with -Enabling -Knowing
Being with
A nurse is documenting in a client's health record using the subjective, objective, assessment, and plan (SOAP) charting model. Which of the following information should be included in the subjective component? -Client administered nitroglycerin 0.3 mg SL for chest pain -Client's skin is pale and diaphoretic -Client's blood pressure is 182/98 mm Hg -Client reports chest pain after mowing lawn this morning
Client reports chest pain after mowing lawn this morning
A nurse is documenting assessment findings on a client. Which of the following entries should the nurse identify as subjective data? -Client reports dull, aching pain in lower right calf. -Client's oral temperature is 38.4° C (101.2° F). -Client has a vesicular rash on their upper back. -Client reports nausea following administration of pain medication. -Client reports the rash on their back is itchy.
Client reports dull, aching pain in lower right calf, Client reports nausea following administration of pain medication, Client reports the rash on their back is itchy
A nurse is preparing to admit a client who has a new diagnosis of methicillin-resistant Staphylococcus aureus (MRSA). The nurse should plan to place the client in which of the following types of transmission-based precautions? -Protective -Contact -Airborne -Droplet
Contact
A nurse is assessing a client who has impaired mobility. The nurse should monitor the client for a pressure injury due to which of the following factors? -Increased muscle mass -Decreased circulation -Increased collagen -Decreased serum calcium
Decreased circulation
A nurse is preparing to insert an indwelling urinary catheter for a client. Which of the following actions should the nurse plan take? -Don sterile gloves before inserting the indwelling urinary catheter. -Use one cotton swab to clean the client's urinary meatus. -Apply an oil-based lubricant to the indwelling urinary catheter. -Test the balloon on the indwelling urinary catheter before insertion.
Don sterile gloves before inserting the indwelling urinary catheter.
A nurse is assessing a client who is nonverbal for acute pain. Which of the following findings is a manifestation of pain? -Reduced respiratory rate -Decreased heart rate -Elevated blood pressure -Constricted pupils
Elevated blood pressure
A nurse is teaching a class about nutrients. The nurse should include that which of the following is a function of fats? -Convert to sugar to provide energy -Regulates nerve cell transmission -Facilitates the absorption of vitamins -Builds and repairs tissue
Facilitates the absorption of vitamins
A nurse is teaching a class about oxygen transport in the cardiopulmonary system. Which of the following transports oxygen in the blood? -Platelets -Lymphocytes -Hemoglobin -Neutrophils
Hemoglobin
A nurse is preparing to change the linens on a client's bed. Which of the following actions should the nurse take? -Hold soiled linen away from the nurse's clothing. -Place soiled linens on the floor while changing the client's bed. -Shake soiled linens before placing them in a bag. -Place the client's bed height in the lowest position.
Hold soiled linen away from the nurse's clothing.
A nurse is caring for a light-skinned client who has an ileostomy. Nurses' Notes Nurses' Notes Day 1: Abdomen soft, nondistended. Ileostomy present. Stoma is red. Stoma draining brown liquid stool. Client will not look at stoma. Client states they are not interested in learning about stoma care. Day 2: Ileostomy pouch changed. Skin surrounding stoma is reddened and has small open areas. The nurse is reviewing the client's medical record. Click to highlight the findings that require intervention by the nurse. To deselect a finding, click on the finding again. Day 1: Abdomen soft, nondistended. Ileostomy present. Stoma is red. Stoma draining brown liquid stool. Client will not look at stoma. Client states they are not interested in learning about stoma care. Day 2: Ileostomy pouch changed. Skin surrounding stoma is reddened and has small open areas. Stoma with small amount of bleeding noted during cleaning.
I dont know sorry guys
A nurse is instructing a newly licensed nurse about the scope and standard of nursing practice. Which of the following describes standards of practice? -Lists a set of skills that all nurses should be competent performing. Outlines responsibilities that every nurse is expected to provide regardless of their role. -Establishes a protocol for care to provide for a specific health problem. -Specifies the nurses provide care that reflects current practice competent level of behavior when providing client care. -Provides competencies for the nurses to achieve before licensure.
Lists a set of skills that all nurses should be competent performing. Outlines responsibilities that every nurse is expected to provide regardless of their role.
A charge nurse is determining client acuity levels. The nurse should consider the time spent completing which of the following tasks when determining acuity? -Assisting others -Meal breaks -Charting -Medication administration
Medication administration
A nurse is completing a SOAP note in a client's chart. In which of the following sections should the client's vital signs be documented? -Plan -Assessment -Subjective -Objective
Objective
A nurse is teaching a newly licensed nurse about orthostatic hypotension. Which of the following information should the nurse include? -Orthostatic hypotension increases a client's risk of a fall. -Orthostatic hypotension increases a client's risk of a pulmonary emboli. -Orthostatic hypotension is indicated by a decrease in systolic blood pressure of 10 mm Hg. -Orthostatic hypotension is indicated by a decrease in diastolic blood pressure of 5 mm Hg.
Orthostatic hypotension increases a client's risk of a fall.
A nurse is providing an in-service to a group of newly licensed nurses on the Nurse Practice Act (NPA). Which of the following is the first step in defining the scope of nursing in the NPA practice? -Identifies a committee/board regulatory body to enforce the law -Enforce regulations and rules for care to provide for a specific problem -Provides competencies for the nurse to achieve Regulate requirements for licensure of nurses. -Pass a law to regulate nursing practice of a law within a state
Pass a law to regulate nursing practice of a law within a state
A nurse is caring for a client who is placed on droplet precautions. Which of the following actions should the nurse take? -Move the client to a positive airflow room. -Place a surgical mask on the client when -they leave their room. -Wear a surgical mask when within 0.6 m (2 ft) of the client. -Remove fresh flowers from the client's room.
Place a surgical mask on the client when they leave their room.
A nurse is preparing to teach a client about a new medication. Which of the following actions should the nurse take? -Turn on the television in the client's room. -Provide educational material written at a 6th grade reading level. -Use technical language in the educational session. -Begin with the least important information.
Provide educational material written at a 6th grade reading level.
A nurse is teaching a class about reducing the risk of medication errors. Which of the following information should the nurse include? -Remove medications from automatic dispensing systems before they are reviewed by pharmacists. -Wait to document medications given to clients until the end of a shift. -Provide the nurse administering medications with an identifying vest. -Prepare medications for multiple clients at the same time.
Provide the nurse administering medications with an identifying vest.
A nurse is teaching a newly licensed nurse about documenting vital signs. Which of the following documentations made by the newly licensed nurse indicates an understanding of the teaching? -Temp 36° C (96.8° F) -BP 148/72 mm Hg -Radial pulse regular 68/min -SpO2 95%
Radial pulse regular 68/min
A nurse is caring for a client. Laboratory Results Vital Signs Nurses' Notes Laboratory Results Day 4: Hct 37% (37% to 47%) Hgb 13 g/dL (12 g/dL to 16 g/dL) WBC 13,500/mm3 (5000 to 10,000 mm3) Vital Signs Day 1: Temp 37.2° C (99° F) BP 122/58 mm Hg HR 78/min R 16/min Pulse oximetry 97% on room air (95% to 100%) Day 4: Temp 38.9° C (102° F) BP 108/56 mm Hg HR 106/min R 24/min Pulse oximetry 95% on room air (95% to 100%) Nurses' Notes Day 1: Client has a 2 cm (0.79 in) x 3 cm (1.2 in) stage 2 pressure injury on right heel. No drainage noted, wound bed is red. Hydrocolloid dressing applied over wound. Day 4: Hydrocolloid dressing removed. Client has a 2.5 cm (1 in) x 3 cm (1.2 in) stage 3 pressure injury on right heel. Redness noted at wound borders, skin surrounding wound is warm to touch, purulent drainage noted. Click to highlight the findings that require follow-up. To deselect a finding, click on the finding again. Wound bed is red. Redness noted at wound borders, skin surrounding wound is warm to touch, purulent drainage noted Temp 38.9° C (102° F) Hct 37% (37% to 47%) WBC 13,500/mm3 (5000 to 10,000 mm3) Click to highlight the findings that require follow-up. To deselect
Redness noted at wound borders, skin surrounding wound is warm to touch, purulent drainage noted Temp 38.9° C (102° F) WBC 13,500/mm3 (5000 to 10,000 mm3)
A nurse is providing an in-service to a group of newly licensed nurses on standards of practice and the role of the Board of Nursing (BON). Which of the following information should the nurse include? -Regulates and monitors laws set by the Nurse Practice Act. -Promotes excellence in nursing education -Determines competencies for the nurses to achieve before licensure. -Establishes a protocol for care to provide for a specific health problem
Regulates and monitors laws set by the Nurse Practice Act.
A nurse is preparing to perform hand hygiene with an alcohol-based hand sanitizer. Which of the following actions should the nurse plan to take? -Rub hand sanitizer around rings on fingers. -Dry hands with a reusable towel. -Use hot water to rinse hand sanitizer off. -Rub hands together for 20 seconds.
Rub hands together for 20 seconds.
A nurse is teaching a newly licensed nurse about pain. Which of the following is an example of acute pain? -Surgical incision -Peripheral neuropathy -Rheumatoid arthritis -Fibromyalgia
Surgical incision
A nurse is teaching a client about how to instill eye drops. The nurse asks the client to explain the procedure in their own words. Which of the following types of teaching methods is the nurse using? -Teach-back -Role play -Lecture -Question and answer
Teach-back
A nurse is assessing a client for manifestations of pain. Which of the following findings is an objective indicator of pain? -The client reports a burning sensation. -The client rates their pain as an 8 on a scale of 0 to 10. -The client states the pain is located on their abdomen. -The client grimaces when they move.
The client grimaces when they move.
A nurse is assessing a client who is receiving intermittent enteral nutrition through a nasogastric tube. Which of the following assessments is the nurse's priority? -The client is experiencing abdominal cramping. -The client reports being thirsty. -The client is regurgitating the enteral formula. -The client is reporting constipation.
The client is regurgitationg the enteral formula
A nurse is assessing a client for manifestations of pain. Which of the following findings is a subjective indicator of pain? -The client's pupils are dilated. -The client is grimacing. -The client is restless. -The client reports a burning sensation.
The client reports a burning sensation.
A nurse is preparing to administer a client's antihypertensive medication. When using clinical judgment, which of the following findings indicates the nurse should further assess the client before administering medication? -The client reports having trouble sleeping the previous night. -The client has a urine output of 400 mL for the past 8 hr. -The client ate 60% of their breakfast. -The client reports dizziness when ambulating to the bathroom.
The client reports dizziness when ambulating to the bathroom.
A nurse is assessing a client who is postoperative.. Which of the following findings should the nurse identify as objective data? -The client states they are experiencing "extreme pain". -The client's current blood pressure is below their preoperative reading. -The client's urine output has been 150 mL over the past 3 hr. -The client is reporting nausea. -The client's right calf is swollen and warm to the touch.
The client's current blood pressure is below their preoperative reading, The client's urine output has been 150 mL over the past 3 hr, The client's right calf is swollen and warm to the touch.
A nurse is writing a teaching plan using the Specific, Measurable, Attainable, Relevant, and Timed outcome (SMART) goals for a client who is learning to walk with crutches. Client Education Client Education Day 1: The client will teach back information about safe crutch walking on day 1. The client will describe: The importance of not placing pressure on their axilla Why they should not use crutches that are not measured for them How to check crutch tips and replace them if they are worn That they should keep crutch tips dry and how to dry them if they become wet How to inspect crutches for damage, such as cracks or bends. The client will demonstrate safe crutch walking. The client will not lean on the crutches to support their body weight. The client will sit in a chair within 2 hrs. The client will stand up from a chair within 2 hrs. The client will ambulate 5 feet in one day. Day 2: The client will walk up 3 stairs by day 2. The client will walk down 3 stairs by day 2. The client will walk 10 feet by day 2. Day 3: The client will walk up 10 stairs by day 3. The client will walk down 10 stairs by day 3. The client will walk 20 feet by day 3. The client will explain 4 principles o
The ones with times in them
A nurse is preparing to lift a heavy object. Which of the following actions by the nurse indicates an understanding of body mechanics? -They keep their feet together when lifting an object. -They twist their spine when lifting. -They bend at the hip when lifting. -They stand close to the object being moved.
They stand close to the object being moved
A nurse is planning to perform perineal care for a female client. Which of the following actions should the nurse plan to take? -Allow the client's perineum to air dry. -Use the same section of washcloth for each area cleaned. -Use soap and water to clean the client's perineum. -Start at the client's rectum and clean to the client's perineum.
Use soap and water to clean the client's perineum.
A nurse is teaching a client about water-soluble vitamins. Which of the following vitamins should the nurse include? -Vitamin E -Vitamin D -Vitamin A -Vitamin C
Vitamin C
A nurse is preparing to administer an enema to a client. Which of the following actions should the nurse plan to take? -Place the client into a right lateral position. -Use sterile technique. -Lubricate the tubing with an oil-based lubricant. -Warm the enema solution to room temperature.
Warm the enema solution to room temperature.
A nurse is caring for a client. Nurses' Notes 0800: Client is admitted with a 3-day history of abdominal cramps and diarrhea. Client reports 4 to 5 liquid stools/day. Client was taking amoxicillin/clavulanate for a respiratory tract infection, 500 mg PO q 12 hr for 10 days. Antibiotics completed 7 days ago. Abdomen soft, nondistended with hyperactive bowel sounds audible in 4 quadrants. Stool contains mucous and is foul-smelling. Stool sent for culture Which of the following actions should the nurse take? Which of the following actions should the nurse take? Select all that apply. -Wear a protective gown while caring for the client. -Place the client in a private room. -Wear an N-95 respirator while caring for the client. -Place the client in a negative pressure room. -Place a mask on the client when they leave their room.
Wear a protective gown while caring for the client. & Place the client in a private room.
A nurse is obtaining informed consent from a client who is scheduled for a procedure. Which of the following roles is the nurse demonstrating? -Nurse manager -Case manager -Researcher -Advocate
advocate
Which of the following is a component of clinical decision-making that the nurse should use to make an evidence-based decision? -Clinical judgement -Concept mapping -Clinical reasoning -Critical thinking
clinical judgement
A nurse looks up information in a client's medical record but is not involved in the care of the client. The nurse is violating which of the following standards of professional performance? -Quality of practice -Evidence-based practice -Collaboration -Code of ethics
code of ethics
A nurse is providing comfort for a client who is experiencing pain. Which of the following categories of Swanson's Theory of Caring is the nurse demonstrating? Doing for Knowing Maintaining belief Enabling
doing for
A nurse is planning to provide discharge teaching for a client who has hearing loss. Which of the following actions should the nurse plan to take? -Answer client's question using medical terminology. -Increase the rate of speech when talking with the client. -Dim the lights in the client's room. -Face the client while talking.
face the client while talking
A nurse is assessing a client who has bradycardia. Which of the following findings should the nurse expect? -Elevated temperature -Fluid volume deficit -Anxiety -Lightheadedness
lightheadedness
A nurse is reviewing a client's medical record. Which of the following findings should the nurse identify as a fall risk? -Hyperlipidemia -Inguinal hernia -Hyperthyroidism -Multiple sclerosis
multiple sclerosis
A nurse is teaching a class about pulmonary circulation. The nurse should include that blood flows from the heart to the lungs from the right ventricle starting from which of the following locations? -Left ventricle -Left atrium -Pulmonary artery -Pulmonary veins
pulmonary artery
A nurse is preparing to reposition a client. Which of the following actions should the nurse take first? -Place their feet in line with their shoulders. -Tighten their abdominal muscles. -Pivot their feet in the direction of the move. -Raise the height of the client's bed.
raise the height of the client's bed
A nurse is teaching a client who is on a low sodium diet. Which of the following instructions should the nurse include? Read labels on foods before eating. Choose bottled salad dressings. Replace fresh meats with processed meats. Limit intake of canned soups to 2 servings.
read labels on foods before eating
A nurse is caring for a client who has an oral temperature of 39.5° C (103.1° F). Which of the following actions should the nurse take? -Restrict the client's fluid intake. -Place a warming blanket over the client. -Increase the temperature in the client's room. -Remove excess clothing from the client.
remove excess clothing from the client
A nurse opens a unit-dose of a prescribed medication prior to administering it to a client. The client refuses to take the medication. Which of the following actions should the nurse take? -Report the incident to the provider. -Fill out an incident report. -Return the opened medication to the medication cart. -Notify the facility's ethics committee.
report the incident to the provider
A nurse is preparing to delegate tasks to an assistive personnel (AP). The nurse should identify which of the following as one of the five rights of delegation? -Right documentation -Right time -Right room -Right communication
right communication
A nurse is teaching a newly licensed nurse about pain. Which of the following is an example of nociceptive pain? -Post-herpetic neuralgia -Diabetic neuropathy -Phantom limb pain -Strained muscle
strained muscle
A nurse is preparing a client for a procedure. Which of the following is an acceptable identifier to use identify the client? -Medical condition -Telephone number -Home address -Room number
telephone number
A nurse is calculating a client's body mass index (BMI). Which of the following information does the nurse require? -The client's daily calorie intake -The client's height -The client's skinfold thickness -The client's waist circumference
the client's height