FUNDAMENTALS TEST 1

Which clients are at a higher risk for orthostatic hypotension?

A 29-year-old pregnant clientAn 80-year-old client with pneumonia A 60-year-old client with vomiting and dehydration

A registered nurse (RN) is assigning clients on her unit. What client can the RN assign to the NAP?

A client who will be discharged in 30 minutes

__ is a broken bone.

A fracture

Which represents an Americans with Disabilities Act (ADA) accommodation?

A nurse who has had a stroke is not physically able to perform client care and is given a position in scheduling, with an associated pay cut.

___ is an injury to a muscle caused by overuse or overstress.

A strain

Mr. Lu is admitted with an abdominal pain. His oral temperature is 100.4°F (38°C), pulse is 88 beats/min, respirations are 18 breaths/min, and blood pressure is 118/78 mm Hg. These findings are: NORMAL/ABNORMAL

ABNORMAL Although the pulse, respiration, and blood pressure are within normal range, the temperature is elevated, which could be related to an infection or inflammation. While normal temperature varies, keep the following in mind: Pyrexia = oral temperature higher than 100°F (37.8°C) Moderate fever = up to 103°F (39.5°C) Hyperpyrexia = above 105.8°F (41.0°C)

A nurse is assisting a client to a standing position. The client requires frequent breaks and is unable to catch his or her breath. After standing for a few seconds, the client states he or she is exhausted and needs to lie down again. Which is an appropriate priority nursing diagnosis for this client?

Activity intolerance

WHICH exercise is when the oxygen taken into the body meets or exceeds oxygen demand.

Aerobic

Which factors impact a client's normal body temperature?

Age gender exercise environment recent intake

Which pulse should the nurse use to obtain a heart rate on an infant?

Apical

___ is joint movement.

Articulation

___ the movement of joints.

Articulation

The nurse asks the unlicensed assistive personnel (UAP) to obtain a blood pressure (BP) from a client admitted with uncontrolled diabetes mellitus and morbid obesity. The client's BP normally ranges from 120/80 to 140/90 mm Hg. The UAP informs the nurse the client's BP is 200/110 mm Hg. Which interventions will the nurse perform?

Assess the client for complications. Check the size of the BP cuff used. Recheck the manual BP

The nurse recognizes that the client has crackles in the lower lung fields from an accumulation of fluid. He further explores the patient's weight, intake and output, and medication list before documenting the findings. CRITICAL THINKING/NOT

CRITICAL THINKING Further inquiry allows the nurse to determine the severity of the findings and whether additional intervention is necessary.

the nurse discovers abnormal findings when performing a physical assessment. She reviews the electronic health record, comparing the findings, and calls the healthcare provider with the contrasting information. The nurse practitioner then gives new medication orders. CRITICAL THINKING/NOT

CRITICAL THINKING The nurse performed further investigation to determine whether the findings were new or had been previously reported. Further reporting identified that additional follow-up was required

The nurse delivers the first dose of a new blood pressure medicine that the client has not taken previously. She assesses the blood pressure before delivery of the medication and 1 hour afterward. Prior to the second dosage, the patient's blood pressure is very low and the nurse decides to hold the medication. CRITICAL THINKING/NOT

CRITICAL THINKING With the patient's best interest in mind, the nurse has gathered data, evaluated the data, and made decisions based on the information.

A nurse decides to place the intravenous catheter into the client's left arm because he is right handed. CRITICAL THINKING/NOT

CRITICAL THINKING Taking patient considerations into account when inserting an intravenous catheter demonstrates critical thinking.

A client tells the nurse that the hospital food is "terrible." The nurse asks what foods the client would prefer based on his cultural customs. She then contacts the dietary department to determine whether adjustments can be made. After the next meal, the nurse asks the client whether the food has improved. CRITICAL THINKING/NOT

CRITICAL THINKING The nurse has identified a problem, assessed the client's individual needs, made adjustments to care, and evaluated whether the changes were effective.

Which complex thinking process is logical thinking that connects thoughts to create meaning?

Clinical reasoning Nurses use logical thinking to connect facts to formulate a plan of care. This is clinical reasoning.

When assessing a client for self-care abilities, what observations should be addressed?

Complete independence Requires a device or special equipment Requires help, supervision, or teaching from another person Is totally dependent

The nurse is performing passive range of motion for a client with osteoarthritis and feels a grating sound in the left knee. How would the nurse document this finding

Crepitus

While assessing Mr. Brown's respiratory rate, you also observe that his chest expands fully on inspiration. His respiratory depth would be considered:

DEEP

Fair access to care and allocation of resources are examples of what type of justice?

Distributive (requires fair distribution of both benefits and burdens and includes allocation of health-care resources and available care for all.)

What is important to remember when conducting perineal care for a client?

Drape the client appropriately to protect modesty. RATIONALE:As each area is cleansed, those areas not being addressed should be draped to avoid embarrassment and protect modesty.

WHICH ACT identifies a surrogate decision maker who is able to make decisions regarding health in the event the client is unable to do so.

Durable power of attorney (DPOA)

A 49-year-old uninsured and unemployed client arrives at the emergency department of the local private hospital closest to home complaining of chest pain radiating between the shoulder blades, tightness in the neck, and nausea. The triage nurse calls the on-call provider, who instructs the nurse to send the client to the county hospital several blocks away. What federal law protects this client against refusal of care at the private hospital?

EMTALA The Emergency Medical Treatment and Active Labor Act (EMTALA) mandates health-care facilities provide emergency medical treatment to clients seeking emergency health care regardless of their ability to pay, legal status, or citizenship status.

Which blood pressure Korotkoff sound represents the systolic reading?

FIRST SOUND systolic BP. Initial sound heard when taking a blood pressure, a tapping sound.

A nurse has multiple clients assigned at the beginning of a shift on the surgical unit. Which client should be assessed first? Female, posthysterectomy, blood pressure 90/52 mm Hg Male, postappendectomy, pain medications administered 15 minutes ago Male, posthip arthroplasty, to be up and ambulating Female, postcholecystectomy, being discharged with wound care and diet instruction

Female, posthysterectomy, blood pressure 90/52 mm Hg Blood pressure below what is considered normal in a postoperative client should be assessed immediately.

Which factor can impede health and extend a client's length of stay in the hospital?

Financial concerns

Which describes the ability to carry out activities of daily living with vigor and alertness, without undue fatigue, and with enough energy for leisure pursuits or to respond to emergencies

Fitness

WHICH position is the client sitting almost upright, with the head of bed elevated to 45 to 90 degrees.

Fowler's position

What should the nurse instruct a group of adults regarding ways to incorporate exercise into the day?

Go for a walk while on break. 3Park your car at end of the parking lot. Take the stairs instead of the elevator.

How is critical-thinking used in nursing other than in the nursing process?

In determining how many nurses to staff during a shift When creating a list of inventory needed for the unit

How is critical-thinking used in nursing other than in the nursing process?

In determining how many nurses to staff during a shift In determining which medications to order to fulfill possible standing physician orders When evaluating a client's response to interventions When creating a list of inventory needed for the unit

WHICH exercise is the use of specialized equipment to provide resistance to movement.

Isokinetic .

Weight training with free weights is an example of which type of exercise?

Isotonic ( movement of a joint from muscle contraction.)

The nurse is discussing the benefits of exercise with a client that has a history of hypertension and atherosclerosis. The client expresses hesitancy about beginning an exercise program with having heart disease. What is the nurse's best response

It is healthier for your heart to exercise than to be sedentary."

WHICH is a side-lying position.

Lateral position

Which would be the most appropriate way of moving a client who is very obese and immobile?

Mechanical lift

Hand hygiene, environmental cleanliness, standard precautions, and protective isolations are components of which infection prevention strategy

Medical asepsis

Which are methods used to prevent orthostatic hypotension problems when clients are standing?

Medications Abdominal binders Antiembolism stockings

Ms. Martin vomited 200 mL of stomach contents after breakfast. Her vital signs include tympanic temperature, 97.6°F (36.4°C); pulse, 99 beats/min; respirations, 16 breaths/min; and blood pressure, 104/67 mm Hg. These findings are: NORMAL/ABNORMAL?

NORMAL Each of these is within the normal parameters for an adult: Temperature: Mean normal adult oral temperature is 97.3°F (36.3°C). Several measurements must be taken on an individual to determine what is "normal" for that person. Exact numbers vary depending on the site assessed. Pulse rate: 60 to 100 beats/min Respirations: 12 to 20 breaths/min Blood pressure: < 120/80 mm Hg

Ms. Weakly presents to the emergency department with difficulty breathing. Her respiratory rate is 28 breaths/min and her pulse is 110 beats/min. Given the situation, this finding is: NORMAL/ABNORMAL?

NORMAL For someone having difficulty breathing, it would be anticipated that the respiratory rate and heart rate would increase. Difficulty breathing is frightening and provokes a lot of anxiety and fear. With this sympathetic response, the heart rate will increase. When the heart rate increases, the cells need more oxygen, thereby increasing the respiratory rate in response.

When a patient's blood pressure decreases, his pulse increases. This finding would be:

NORMAL Cardiac output is dependent on the strength of the heart's contraction, the amount of blood volume in the body, the resistance the heart has to pump against with each beat, and the heart rate. When blood pressure falls, the heart rate increases to sustain the same amount of blood being pumped with each heart beat (cardiac output).

When a patient's temperature increases, the pulse rate also increases. This finding would be: NORMAL/ABNORMAL?

NORMAL The pulse rate is dependent on the heart rate. Many things impact the heart rate including body temperature, hydration status, blood volume, and medications

The unlicensed assistive personnel reports to the nurse that the blood pressure for a client is very low. The nurse reports the information to the next shift CRITICAL THINKING/NOT

NOT CRITICAL THINKING A critical-thinking nurse would question the results, reevaluate the findings, and confirm that the information is correct. If the findings are correct, the critical-thinking nurse would then determine next steps.

Without assistance, a student ambulates a client in the hallway who recently returned from surgery. CRITICAL THINKING/NOT CRITICAL THINKING

NOT CRITICAL THINKING Clients can be unstable after surgery and there are several reasons for concern, including dizziness, incisional damage, bleeding, and changes in vital signs. The nurse must be aware of the individual client's needs when determining when and how to ambulate the client for the first time after surgery.

The student explores the client's health record, reads the history and physical examination, and records the information on the nursing care plan. CRITICAL THINKING/NOT

NOT CRITICAL THINKING The process of data collection and recording do not require critical-thinking skills.

The nurse gathers equipment for the insertion of a Foley catheter, obtains a verbal consent from the client, and follows the agency's procedure to complete the task. CRITICAL THINKING/NOT

NOT critical thinking The nurse is completing a task that follows a specific step-by-step procedure and thus does not require critical thinking.

Which are examples of primary defenses of the body against infection? Select all that apply.

Normal flora Skin Saliva

Which aspects influence a nurse's ability to use critical thinking?

Nursing uses knowledge from other fields. Nursing is fast-paced. The field of nursing is an applied discipline.

In which position should the nurse place the client with chronic obstructive pulmonary disease (COPD) who is short of breath?

Orthopneic sitting at a 90° angle with a pillow over the bed table in front of the client. This facilitates lung expansion.

When assessing pallor in a light-skinned client, how does the skin appear?

Pale without underlying tones of pink

Which jobs are performed by a nursing manager in order to promote unit effectiveness?

Performance evaluations Job analysis and redesign Hiring and terminating employees

Which describes the attachment of a muscle to a more stable bone?

Point of origin

WHICH position is the client lying on his or her stomach.

Prone position

What are the goals of infection prevention and control in health care?

Protect clients from contagions. Lower the cost of health care services meet professional standards and guidelines. Protect clients from contagions.

NORMAL RANGES Pulse rate: beats/min Respirations: breaths/min Blood pressure: mm Hg

Pulse rate: 60 to 100 beats/min Respirations: 12 to 20 breaths/min Blood pressure: < 120/80 mm Hg

At the beginning of a visit, the nurse assesses Mr. Broda's blood pressure and finds it is 116/76 mm Hg. During the visit, Mr. Broda receives some disturbing news about a diagnostic test. If his blood pressure was reassessed at that time, you would expect it to:

RISE When a person is under physical or emotional stress, a normal sympathetic nervous system response causes blood pressure to rise quickly.

The nurse is learning the differences between primary and secondary hypertension. What is secondary hypertension caused by?

Renal and endocrine disorders NSAIDS Oral contraceptives Nicotine Age RATIONALE: Secondary hypertension is caused by effects from other diseases such as renal failure and diabetes.

Which position is described as the client in a semi-recumbent position, with the head of the bed elevated to 30 degrees?

Semi-Fowler's position (involves the client lying on his or her back with the head of the bed elevated to 30 degrees.)

position elevates the client to a 45° angle. This would be the position for a client receiving tube feeding

Semi-fowler's

Which describes the stretching of a ligament that causes the ligament to tear?

Sprain

While palpating Ms. Smith's pulse, you find a rate of 116 beats/min. This finding is considered _______.

Tachycardia The range for normal pulse rates for healthy adults is 60 to 100 beats/min. Tachycardia is elevated heart rate (> 100 beats/min). Bradycardia is decreased heart rate (< 60 beats/min).

What can the nurse include in the day at work to minimize stress and maintain health?

Take a 20-minute walk on a break.

A nurse has asked the unlicensed assistant personnel (UAP) to take vital signs on six clients. Which traditional measurements do vital signs include

Temperature, pulse, respirations, and blood pressure

this act identifies a client's right to make informed decisions regarding his or her health care.

The Patient Self-Determination Act (PSDA)

The nurse in a community clinic is assessing a 23-year-old client who reports upper respiratory congestion and a cough that has lingered for 3 weeks. In the initial interview, the nurse learns the client's family lives out of state and that the client goes to school part-time while waiting tables part-time. What might the nurse infer from this information?

The client has most likely not had a recent physical examination.

How can a nurse determine that teaching has been effective

The client is able to repeat back the instructions given.

Which type of joint is a synovial joint?

The knee joints are synovial joints that are freely movable.

The nurse is assigned to care for a client who reports nausea, vomiting, and diarrhea. The client's vital signs are as follows: T 100.6°F, AP 100, RR 20, BP 92/69, O2 saturation 98%. Which nursing actions represent the nurse using critical-thinking skills to separate important from unimportant data?

The nurse asks what the client has eaten in the past 24 hours. The nurse asks the client how long the symptoms have been present. The nurse assesses the skin turgor of the client.

Which type of bath is most likely to be a medical order?

Therapeutic bath A therapeutic bath is one that is given for a specific reason and is a medical order.

Prior to administering pain medication, the nurse attempts to educate the client on caring for a postoperative wound by demonstrating proper cleaning and dressing change techniques. The nurse has conducted this teaching in the client's room and has had the client demonstrate the proper technique and repeat when to change the dressing and why. Which "right" has not been addressed in this situation?

Timing

the nurse is working with a 57-year-old client who is worried about exercising too hard. What would be this client's maximum heart rate for high-intensity exercise?

To determine this value, the nurse would subtract the client's age from 220 and then multiply the result by 0.85. This would be 220 - 57 = 163 X 0.85 = 138 beats per minute.

under WHICH ACT health-care agencies are required to notify clients of any breach of information without unreasonable delay and by no longer than 60 days.

Under the HITECH Act

When creating a password for computer usage, what are some important factors that should be kept in mind?

Use combinations of letters, numbers, and symbols. Don't use words or numbers that are easy to guess. change passwords frequently. Never share passwords with others.

Which environmental factors could prevent a person from exercising on a consistent basis? Select all that apply.

Weather Pollutants financial strain

Which are guidelines for good body mechanics? Select all that apply.

Wide base of support Abdominal muscles tight Chest high

Ms. Hernandez has a temperature of 102.5°F. Antipyretic medication is ordered for a temperature higher than 39°C. Can the nurse safely administer the medication? YES/NO?

YES The nurse must first convert the Fahrenheit temperature to Celsius using this formula: °C = (°F - 32) × 5/9 °C = (70.5 × 5) ÷ 9 °C = 39.2 Because Ms. Hernandez's temperature is > 39°C, it is safe to give the antipyretic medication.

Which factors should the nurse assess prior to giving a client directions for beginning an exercise program?

age smoker overweight

Which are components of caring?

being with Knowing Enabling Maintaining belief

What are the effects of immobility on the gastrointestinal system?

constipation heartburn nausea

The nursing supervisor has developed a new protocol for implementing family support through family-centered care. The majority of the staff is apprehensive about trying the new procedure. If the supervisor continues with implementing the plan, which critical-thinking attitude is he or she displaying?

courage

hat would be an appropriate outcome for a nursing diagnosis of Impaired Walking r/t foot pain secondary to arthritis?

demonstrates measures to increase mobility

how frequently should clients with limited mobility be repositioned in bed?

every 2 hours

The point of ____is the attachment of a muscle to a moveable bone.

insertion

___ exercise is muscle contraction without motion.

issometric

Which areas should the nurse include when performing a health assessment?

mental status physical status cultural status socioeconomical status

The supine position would be most beneficial for a client

on bed rest after a cardiac catheterization

Which gases are primarily exchanged during respiration?

oxygen carbon dioxide

Which describe types of muscle?

skeletal caridac smooth

Which credible sources of information should the nurse use to obtain information about the client when developing a plan of care?

spouse electronic medical record nursing textbooks

Which health-care related infections is the U.S. Department of Health and Human Services (USDHHS) working to reduce?

surgical site infections Multidrug-resistant organisms ventilator-associated pneumonia Catheter-associated urinary tract infections

When arriving to take a client's blood pressure, a nurse witnesses an argument between the client and spouse. Recognizing that stress can alter blood pressure, the nurse encourages the spouse to step out and get something to drink, giving the client an opportunity to calm down. The nurse returns later to take the client's blood pressure after the client has had time to settle down. What is true about this situation?

the nurse used practical knowledge by communicating with the spouse and suggesting a break in order to get an accurate reading.

If the body is overheating, it will compensate with

vasodilatation