Fundamentals

A nurse is caring for a client who has terminal illness and is at the end of life. The nurse should recognize that which of the following statements by the client's partner indicates effective coping?

"I am relying on support from our family during this time."; this statement indicates effective coping because the partner is relying on others in the family for support during a time of crisis.

A nurse is performing a skin assessment for a client who expresses concern about skin cancer. Which of the following findings should the nurse identify as a potential indication of a skin malignancy?

A mole with an asymmetrical appearance?

A nurse is assessing a client who has required bed rest for the past month. Which of the following findings should the nurse identify as an indication that the client has developed thrombophlebitis

Calf Swelling; swelling, redness, and tenderness in a calf muscle are manifestations of thrombophlebitis, a common complication of immobility.

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

Droplet

a nurse is planning to insert a peripheral IV catheter in an older adult client. which of the following actions should the nurse plan to take?

Place the client's arm in a dependent position; the nurse should place the client's arm in a dependent position because the veins will dilate due to gravity.

A nurse is using an open irrigation technique to irrigate a client's indwelling urinary catheter. Which of the following actions should the nurse take?

Subtract the amount of irrigant used from the client's urine output; the nurse should calculate the fluid used for irrigation and subtract it from the client's total urinary output.

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

Decrease in heart rate: fluid volume deficit causes tachycardia. With correction of the imbalance, the heart rate should return to the expected range.

A nurse is talking with the partner of a client who has dementia. The client's partner expresses frustration about finding time to manage household responsibilities while caring for his partner. The nurse should identify that he is going through which of the following types of role-performance stress?

Role overload; the partner's expression of frustration is an example of role overload, which refers to having more responsibilities within a role than one person can manage

A nurse is providing discharge instructions to a client who will be using a walker. Which of the following statements indicates an understanding of the teaching?

"I will hire someone to trim the tree that hangs low over the stairs of my front porch."

A 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 (AP) select all that apply

1. assist with partial bed bath 2. measure BP after nurse gives antihypertensive meds 3. test the clients swallowing ability by providing thickened liquids 4. use a communication board to ask what the client wants for lunch 5. irrigate indwelling catheter 1,2,4

a 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 mL/hr 1. what is the unit of measurement to calculate? mL/hr 2. what is the volume needed? 750 mL 3. what si the total infusion time? 7 hr 4. should the nurse convert the units of measurement? no 5. set up equation and solve for X. volume/time = X 750/7= X 107.14 rounded = 107

A nurse is admitting a new client. Which of the following actions should the nurse take while performing medication reconciliation?

Compare the client's home medications with the provider's prescriptions; the nurse should compare the client's home medications with the provider's prescriptions when performing medication reconciliation.

A 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 process

A nurse is assessing four adult clients. Which of the following physical assessment techniques should the nurse use?

Ensure the bladder of the blood pressure cuff surrounds 80% of the client's arm

A 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 when outside her room if there is construction in the area; allogeneic stem cell transplant compromises the client's immune system, greatly increasing the risk for infection. The client will need protection from breathing in any pathogens in the environment.

A nurse is auscultating the anterior chest wall of a client newly admitted to a medical-surgical unit. Identify the type of breath sounds.

Normal breath sounds

A nurse on a med-surg 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 applying the restraints; the use of restraints without padding can abrade the client's skin, resulting in client injury.

A nurse is administering an otic medication to an older adult client. Which of the following actions should the nurse take to ensure that the medication reaches the inner ear?

Press gently on the tragus of the client's ear; pressing gently on the tragus of the ear will help the medication get into the inner ear.

A nurse is caring for a client who has dementia. Which of the following interventions should the nurse take to minimize the risk for injury to the client?

Use a bed exit alarm system; the nurse should identify that the client who has dementia requires assistance when exiting their bed and might be unable to remember to ask for help. The client's condition places them at risk for falling, therefore, a bed alarm system can alert the staff members that the client is trying to get out of bed and requires assistance.

A nurse is planning strategies to manage time effectively for client care. Which of the following strategies should the nurse implement?

Use the planning step of the nursing process to prioritize client care delivery.

A home health nurse is performing a follow-up visit for a client who has a gastrostomy tube through which they receive intermittent feedings and medications. The client has recently developed diarrhea. Which of the following findings should the nurse identify as a possible cause of the diarrhea?

The client's caregiver washes out the feeding back with warm water once every 24 hours; feeding bags should be washed out after each feeding and replaced with a new feeding bag every 24 hours to prevent bacterial contamination. The nurse should reinforce this information with the client's caregiver.

A nurse is caring fro a client who is postoperative and has signs of hemorrhagic shock. when the nurse notifies the surgeon, he directs her to continue to take 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 the nurse manager; the greatest risk to the client is not receiving timely intervention for his deterioration in physiological status; therefore, the next action the nurse should take is to activate the chain of command to ensure the necessary care.