Fundamentals pre-assessment quiz

A nurse is caring for a client with a closed head injury. When pressure is applied to the client's nail beds, the client's eyes open and adduction of the arms with flexion of the elbows and wrists is noted. The client also moans with stimulation. What is the client's Glasgow Coma Score?

7 The GCS is calculated by using appropriate stimuli (a painful stimulus may be necessary such as pressure to the nail beds) and then assessing the client's response in three areas. Eye opening (E)- the best eye response, with responses ranging from 4 to 1 4= Eye opening occurs spontaneously 3= Eye opening occurs secondary to voice 2= Eye opening occurs secondary to pain 1= Eye opening does not occur Verbal (V)- The best verbal response, with responses ranging from 5 to 1 5= Conversation is coherent and oriented 4= Conversation is incoherent and disoriented 3= Words are spoken, but inappropriately 2= Sounds are made, but no words 1= Vocalization does not occur Motor (M)- The best motor response, with responses ranging from 6 to 1 6= Commands are followed 5= Local reaction to pain occurs 4= There is a general withdrawal to pain 3= Decorticate posture (adduction of arms, flexion of elbows and wrists) is present 2= Decerebrate posture (abduction of arms, extension of elbows and wrists) is present 1= Motor response does not occur

A nurse should teach which of the following clients requiring crutches about how to use a three-point gait?

A client who has a right femur fracture with no weight bearing on the affected leg A three-point gait is appropriate for this client. A three-point gait requires the client to bear all of his weight on one foot. With a three-point gait, the client bears weight on both crutches and then on the uninvolved leg, repeating the sequence. The affected leg does not touch the ground.

A nurse is assessing four clients for fluid balance. The nurse should identify that which of the following clients is exhibiting manifestations of dehydration?

A client who has a temperature of 30C (102F) This temperature is greater than the expected reference range of 36C (96.8F) to 37C (98.6). An elevated temperature is a manifestation of dehydration.

A nurse is admitting a client who has tuberculosis and a productive cough. Which of the following types of isolation precautions should the nurse initiate for the client?

Airborne The nurse should initiate airborne precautions when a client has an infection that spreads through small droplets that remain airborne for longer periods, such as tuberculosis and measles. The client requires a negative-pressure airflow room, and staff should wear an N95 respirator when in contact with the client.

A nurse is caring for a client receiving chemotherapy that is experiencing neutropenia. Which of the following should the nurse include in this client's education?

Avoid crowded events Clients with neutropenia do not have enough circulating neutrophils to fight off infections. This client should avoid crowds to prevent exposure to colds/viruses.

A nurse is assessing a client who has Parkinson's disease. Which of the following manifestations should the nurse expect?

Bradykinesia The nurse should expect to find bradykinesia or difficulty moving in a client who has Parkinson's disease

Which of the following can cause a low pulse oximetry reading?

Inadequate peripheral circulation Inadequate peripheral circulation can generate a low reading.

A client with a cystocele is encouraged to exercise to strengthen pelvic floor muscles and prevent pelvic organ prolapse. What exercise will the client need to perform?

Kegel exercises Kegel exercises strengthen the pelvic floor muscles, which results in reduction or prevention of pelvic prolapse and stress urinary incontinence.

A nurse is caring for a client with a stage 2 pressure ulcer. Define the characteristics of the ulcer.

Partial-thickness skin loss involving the epidermis and the dermis. The ulcer is visible and superficial and may appear as an abrasion, blister, or shallow crater. Edema persists, and the ulcer may become infected, possibly with pain and scant drainage.

A nurse is caring for a client with heart failure who has evidence of dyspnea, bibasilar crackles and frothy sputum. What dietary recommendations should be provided to this client in management of their heart failure?

Reduce sodium intake It is encouraged to stop smoking, reduce sodium intake, monitor fluid intake, restricting intake to 2 L per day. It is also encouraged to increase protein intake to 1.12 g/kg and consume small, frequent meals that are soft, easy-to-chew foods. There are no recommendations on calcium intake associated with heart failure.

A nurse is providing dietary education to a client with cholecystitis who has been prescribed a low-fat diet. Which of the following meal selections by the client indicates understanding of education?

Roast turkey, rice pilaf, green beans Roast turkey is a low-fat protein option that would be an excellent choice for a low-fat diet.

A client with hearing loss has been fitted for a hearing aid. Which of the following teaching points are important for the nurse to discuss with the client?

Use a mild soap and water to clean the ear mold.

A nurse is caring for a client who is admitted for observation and has full range of motion. Which is the best manner to encourage this client to void?

client bathroom The goal is to encourage clients to maintain independence and privacy if the client has full function and is able to safely complete ADLs.

A nurse is providing teaching about the Mediterranean diet to a client who has a new diagnosis of hypertension. Which of the following statements by the client indicates a need for further teaching?

"I will limit my intake of red meat to twice weekly" This statement by the client indicates a need for further teaching. Following the Mediterranean diet, red meat should be limited to two times monthly.

A nurse is caring for an older adult client with delirium. Which intervention will most effectively reduce the client's risk for falls?

hourly rounding by the nurse In the health care environment, hourly rounding by nurses significantly reduces the occurrence of client falls, as well as reducing call light usage and increasing client satisfaction.

A nurse is caring for a client with celiac disease. Which foods should be removed from the meal tray?

tortillas

A nurse is preparing to administer 250 mg of an antibiotic IM. Available is 3 g/5ml. How many mL should the nurse administer per dose? (round to the nearest tenth.)

0.4mL

A nurse is caring for a client receiving radiation treatments for cancer. The client states he is experiencing dryness, redness and scaling at the treatment area. Which of the following should the nurse instruct the client to do?

Liberally apply prescribed lotion to the area Hydrating lotions are commonly prescribed to treat irradiated areas. The client should avoid applying other lotions not prescribed by the radiologist to the affected areas.

What is the name of a legal document that instructs health care providers and family members about what, if any, life-sustaining treatment an individual wants if at some time the individual is unable to make decisions.

Living will A living will is a legal document that specifically outlines a clients wishes regarding life-sustaining treatment

A nurse is caring for a client receiving opiates for pain management. Initially after the pain management plan was started, the client was sedated and sleeping most of the time. After three days on the plan the client is no longer sedated and sleeping regularly. What action should the nurse take?

No action is needed at this time Opiates initially cause sedation but this effect subsides with maintenance pain control. The pain management plan is working. There is no need to change or add additional methods at this time.

A nurse is preparing to administer total parenteral nutrition (TPN) to a client. Which of the following findings indicates a need to obtain a new bag of TPN before administering?

The TPN solution has an oily appearance and a layer of fat on top of the solution Before administration of TPN, the nurse should look for "cracking" of TPN solution. This occurs if the calcium or phosphorous content is high or if poor-salt albumin is added. A "cracked" TPN solution has an oily appearance or a layer of fat on top of the solution and should not be used.

A nurse is assisting a client with his meal that is at risk for aspiration due to a stroke. What interventions should the nurse take to prevent aspiration? Select all that apply.

To decrease the risk of aspiration for a stroke client, ensure the clients position is upright, that the upper back and head are supported during meals. Remind the client to tuck their chin when swallowing, to guide the food's path. Avoid lowering the head of bed during feedings. oral care can improve the client's well-being and increase interest for eating, but does not help prevent the potential for aspiration.

A nurse manager is providing staff education on the correct use of restraints. Which of the following should be included in this education? (select all that apply)

1. Restraints should not interfere with treatment 2. Restraints should not be used because of short staffing 4. Staff must document type and location of the restraint and time applied 5. Assess neurovascular and neurosensory status every 2 hours Restraints should be applied as a last resort after other measures have been used. Thorough and timely documentation needs to be completed when restraints are applied, following protocol and policy. Neurovascular and neurosensory status should be assessed every 2 hours, along with frequent check-ins to ensure the safety and comfort of the client. Restraints should not be used as a way to contain the client when a unit is short-staffed. The type or technique of restraint used must be the least restrictive intervention possible and should never interfere with treatment.

A nurse is verifying nasogastric tube placement by the pH of aspirated gastric fluid. Which of the following pH values provides a good indication of correct tube placement?

2 A good indication of appropriate placement is obtaining gastric contents with a pH between 0 and 4.

A nurse is completing a nutritional assessment on a client and measures body mass index (BMI). Which of the following readings correlates with a BMI of an overweight client?

25 Overweight is defined as an increased body weight in relation to height. It is indicated by a BMI of 25 to 29.9

A nurse is caring for a client with encephalopathy secondary to liver failure. The client has been prescribed a high calorie, low protein diet. Which of the following meal selections is appropriate for this client?

Chicken breast, mashed potatoes, spinach This option meets the prescribed diet. It is high in calories and while chicken does provide protein it is a low-fat source and can be eaten in moderation on a low-protein diet. Spinach will provide additional vitamin K for this client at risk for bleeding due to liver failure.

A nurse is reviewing psychosocial stages of development for a school-age child. What would be an expected behavioral finding for this child?

Develop a sense of industry through advances in learning. Strive to develop health self-respect by finding out in what areas they excel. Peer groups play important role in social development. This behavior is an expected finding of School-age children 6-12 years.

A menopausal client is having difficulty getting to sleep and asks what actions she should incorporate in her daily routine to promote sleep. The nurse would encourage, which of the below measures to promote sleep?

Limit alcohol and nicotine prior to bedtime Limit alcohol, caffeine, and nicotine at least 4 hr before bedtime.

A nurse is caring for a client who has been prescribed furosemide. Which of the following foods should the nurse encourage this to include in his diet?

Oranges Clients prescribed potassium-wasting diuretics should be encouraged to eat foods high in potassium. Oranges, dried fruits, tomatoes, avocados, dried peas, emats, broccoli, and bananas are all good sources of potassium

A nurse is caring for several clients prescribed heat/cold therapies. Which of the following clients are at risk of injury from these therapies? (select all that apply)

The nurse should use extreme caution with clients who are very young, an older adult, fair-skinned, who have impaired cognition, and have comorbidities because they are at higher risk for fragile skin.