Fundaments #1
A nurse is presenting an in-service training session about nutrition. Which of the following simple sugars should the nurse identify as the carbohydrate found in milk? A. Lactose B. Sucrose C. Maltose D. Fructose
Correct Answer: A. Lactose The nurse should identify that lactose is a form of sugar that is found in milk. Incorrect Answers: B. Sucrose is table sugar and is also found in fruits and vegetables. C. Maltose is found in germinating cereals, such as barley. D. Fructose is found in honey and fruit.
A nurse at a screening clinic is assessing a client who reports a history of a heart murmur related to aortic valve stenosis. At which of the following anatomical areas should the nurse place the stethoscope to auscultate the aortic valve? A. Fifth intercostal space just medial to the midclavicular line B. Second intercostal space to the left of the sternum C. Fifth intercostal space to the left of the sternum D. Second intercostal space to the right of the sternum
Correct Answer: D. Second intercostal space to the right of the sternum The aortic valve is located in the second intercostal space to the right of the sternum. Aortic stenosis produces a mid-systolic ejection murmur that can be heard clearly at the aortic area with the client leaning forward. Incorrect Answers: A. The mitral valve is located in the fifth intercostal space just medial to the midclavicular line. B. The pulmonic valve is located in the second intercostal space to the left of the sternum. C. The tricuspid valve is located in the fifth intercostal space to the left of the sternum.
A nurse is providing discharge teaching to a client who is recovering from lung cancer. The provider instructed the client that he could resume lower-intensity activities of daily living. Which of the following activities should the nurse recommend to the client? A. Sweeping the floor B. Shoveling snow C. Cleaning windows D. Washing dishes
Correct Answer: D. Washing dishes Washing dishes requires a low level of activity and is appropriate for this client. Incorrect Answers: A. Sweeping the floor is a moderate-intensity activity. B. Shoveling snow is a high-intensity activity. C. Cleaning windows is a moderate-intensity activity.
A nurse is caring for a client who has emphysema. The client has not stopped smoking cigarettes and states, "It's too late for me to quit." Which of the following actions should the nurse take? A. Assist the client in finding local smoking-cessation assistance programs B. Tell the client that she will be all right after receiving medical care C. Inform the client that she must stop smoking or the provider will not be able to care for her D. Advocate for the client by supporting her statement about not quitting
Correct Answer: A. Assist the client in finding local smoking-cessation assistance programs Smoking cessation slows the progression of chronic obstructive pulmonary disease (COPD). It is not "too late" for this client to stop smoking, and the nurse should encourage the client to do so. Incorrect Answers: B. This is an example of the nontherapeutic communication technique of giving false reassurance. Without smoking cessation, the client's condition will likely deteriorate further. C. Threatening the client with potential harm due to lack of care is unethical and abusive. This action by the nurse will not help the client stop smoking. Also, in this context, the nurse's action violates the ethical principle of beneficence. D. Advocacy aims to improve a client's health and safety. Rather than advocating for the client, the nurse is simply agreeing with the client, which is a nontherapeutic communication technique.
A nurse is removing personal protective equipment (PPE) after performing a procedure for a client who requires isolation precautions. Which of the following items of PPE should the nurse remove first? A. Gloves B. Gown C. Eyewear D. Mask
Correct Answer: A. Gloves According to evidence-based practice, the nurse should first remove the gloves because they are the most contaminated piece of PPE. Next, the nurse should remove the goggles or face shield and then the gown. Finally, the nurse should remove the respirator or mask because it is the least contaminated piece of PPE. Incorrect Answers: B. C. D. According to evidence-based practice, nurses should remove the most contaminated piece of PPE first and the least contaminated piece of PPE last. The most contaminated piece of PPE are the gloves, and the least contaminated piece of PPE is the mask.
A nurse is planning to perform passive range-of-motion exercises for a client. Which of the following actions should the nurse take? A. Repeat each joint motion 5 times during each session B. Move the joint to the point of considerable resistance C. Sit approximately 2 ft from the side of the bed closest to the joint being exercised D. Exercise the smaller joints first
Correct Answer: A. Repeat each joint motion 5 times during each session To maintain the client's joint mobility, the nurse should repeat each motion 3 to 5 times. Incorrect Answers: B. The nurse should move the joint to the point of slight resistance. C. The nurse should stand at the side of the bed closest to the joint being exercised. D. The nurse should exercise the large joints first.
A nurse is assessing a client's incision and observes the drainage to be blood-tinged. Which of the following terms should the nurse use to document this finding? A. Sanguineous B. Purulent C. Serous D. Hyperemia
Correct Answer: A. Sanguineous The nurse should document blood-tinged drainage as sanguineous. This type of drainage contains large amounts of red blood cells, indicating that damaged capillaries are allowing the escape of red blood cells from the plasma. Incorrect Answers: B. The nurse should identify that purulent drainage is exudate that is thicker than other drainages, indicating the presence of pus. This pus consists of leukocytes, liquefied dead tissue debris, and dead and living bacteria. C. The nurse should identify serous drainage as exudate that is mostly serum, which is the clear portion of the blood. It appears watery and contains few cells. D. The nurse should identify hyperemia as a red coloration of the skin in clients who have light skin or as a blue coloration of the skin in clients who have dark skin. Hyperemia is not a type of drainage.
A nurse is caring for a client who has peripheral edema. The nurse should identify that which of the following nutrients regulates extracellular fluid volume? A. Sodium B. Calcium C. Potassium D. Magnesium
Correct Answer: A. Sodium Sodium regulates extracellular fluid balance, nerve impulse transmission, acid-base balance, and various other cellular activities. Incorrect Answers: B. Calcium supports bone and tooth formation and facilitates nerve impulse transmission. However, it does not affect extracellular fluid volume. C. Potassium affects storage of glycogen, nerve impulse transmission, cardiac conduction, and smooth muscle contraction. However, it does not affect extracellular fluid volume. D. Magnesium affects enzyme and neurochemical activities and the excitability of cardiac and skeletal muscles. However, it does not affect extracellular fluid volume.
A nurse is providing teaching to a client with heart failure about reducing his daily intake of sodium. Which of the following factors is the most important in determining the client's ability to learn new dietary habits? A. The involvement of the client in planning the change B. The emphasis the provider places on the dietary changes C. The learning theory the nurse uses to teach the dietary changes D. The extent of the dietary changes planned for the client
Correct Answer: A. The involvement of the client in planning the change According to evidence-based practice, client involvement in planning dietary changes is the most important factor in the client's ability to learn new habits. Incorrect Answers: B. The emphasis the provider places on the dietary changes can influence the client's ability to learn new dietary habits; however, it is not the most important factor. C. The learning theory the nurse uses to teach dietary changes can influence the client's ability to learn new dietary habits; however, it is not the most important factor. D. The extent of the changes planned can influence the client's ability to learn new dietary habits; however, it is not the most important factor.
A nurse is providing discharge teaching to a client who has a prescription for daily wound care via home health services. Which of the following statements by the client indicates an understanding of the teaching? A. "A nurse will show me how to care for my wound." B. "A nurse will stay with me at home during the day." C. "I will call the nurse to change my bed linens." D. "I will call the nurse to help me bathe in the morning."
Correct Answer: A. "A nurse will show me how to care for my wound." The home health nurse will provide wound care as prescribed and educate the client about wound care and illness management. Incorrect Answers: B. A client who will receive daily wound care will not require a nurse to stay throughout the day. The home health nurse can make a referral for a home health aide to stay with the client if needed. C. If needed, the home health nurse can make a referral to a home health aide to provide personal care, such as changing bed linens. D. If needed, the home health nurse can make a referral to a home health aide to provide personal care, such as bathing.
A nurse is caring for a client who has a temperature of 38.7°C(101.7°F). Which of the following actions should the nurse take? A. Apply an alcohol-water solution to the client's skin B. Keep the client's bed linens dry C. Apply ice packs to the groin D. Limit the client's fluid intake to 1183 mL (40 oz) of fluid per day
Correct Answer: B. Keep the client's bed linens dry The nurse should maximize the client's heat loss by keeping the client's clothes and bed linens dry. The nurse should also reduce external coverings on the client's bed without causing shivering. Incorrect Answers: A. This therapy is no longer recommended as an intervention for a fever because it can lead to shivering, which is counterproductive and can cause an increase in energy expenditure. C. This therapy is no longer recommended as an intervention for fever because it can lead to shivering, which is counterproductive and can cause an increase in energy expenditure. D. The nurse should satisfy the client's increased metabolic needs by providing the client with at least 1893 mL (64 oz) of fluid per day.
A nurse is providing discharge teaching to an older adult client about personal safety. Which of the following statements by the client indicates an understanding of the teaching? A. "I will have the steps to my house painted a dark color." B. "I will put a night-light in the hallway." C. "I will put on socks when I get out of bed." D. "I will secure any wires in my home under rugs."
Correct Answer: B. "I will put a night-light in the hallway." The nurse should instruct the client to use night-lights in and around the home as an important safety measure to reduce the risk of falls in the home. Physiological changes associated with aging can affect an older adult client's ability to see surroundings. Older adults and infants are at an increased risk of serious injury from falls, and most falls occur in the client's home. Incorrect Answers: A. The nurse should instruct the client to paint or mark only the edges of the steps with a light color to make them more prominent. Physiological changes associated with aging can affect an older adult client's ability to see the edges of the steps. C. The nurse should instruct the client to wear well-fitting slippers with non-skid soles as an important safety measure to reduce the risk of falls in the home. Physiological changes associated with aging can affect an older adult client's ability to balance, increasing the risk of falls. D. The nurse should instruct the client that securing wires under a rug can create an electrical hazard and should be avoided. Physiological changes associated with aging can affect an older adult client's ability to see surroundings and to react quickly to hazards when walking.
A nurse is providing teaching about proper care to a client who has a new colostomy. Which of the following pieces of information should the nurse include in the teaching? A. Change the colostomy bag following breakfast B. Cleanse the skin around the stoma with warm water C. Change the pouch every day D. Place an aspirin in the ostomy pouch to decrease odor
Correct Answer: B. Cleanse the skin around the stoma with warm water The nurse should instruct the client to cleanse the skin around the stoma with warm water, as using soap can leave a residue on the skin and cause poor adherence of the pouch. Incorrect Answers: A. The nurse should instruct the client to change the colostomy bag before a meal because drainage from the ostomy is less likely to occur. C. The nurse should instruct the client to change the pouch every 3 to 7 days to avoid skin breakdown around the stoma. D. The nurse should instruct the client not to place an aspirin in the ostomy pouch to decrease odor, as this can cause stoma bleeding.
A nurse is caring for an adult client who has an NG tube in place and a prescription for continuous enteral feedings. Which of the following actions should the nurse perform to reduce the client's risk of aspiration? A. Irrigate the tubing with 30 mL of sterile water B. Elevate the head of the bed to 30° or 45° C. Suggest changing the feeding to lactose-free formula D. Warm the enteral formula to room temperature before feeding
Correct Answer: B. Elevate the head of the bed to 30° or 45° Elevating the head of the bed to at least 30° and preferably 45° helps prevent the gravitational reflux of gastric contents, thereby decreasing the risk of aspiration. Incorrect Answers: A. Irrigating the tubing will not reduce the client's risk of aspiration. Irrigation can help prevent or resolve clogging of the tube. C. Changing the feeding to lactose-free formula will not decrease the client's risk of aspiration. It will reduce gastrointestinal irritation or upset in clients who are sensitive to lactose. D. Warming the enteral formula before feeding will not decrease the client's risk of aspiration. It can help reduce abdominal cramping and discomfort from cold formula ingestion.
A nurse is preparing to administer a feeding via a gastrostomy tube to a client who had a stroke. Which of the following actions should the nurse take prior to initiating the feeding? A. Warm the feeding in a microwave oven B. Elevate the head of the client's bed C. Flush the tube with 0.9% sodium chloride for irrigation D. Verify that the client's gastric pH is above 4
Correct Answer: B. Elevate the head of the client's bed Clients who have a brain injury are typically unable to swallow effectively and thus cannot protect their airway from aspiration. Even though this route bypasses the nasopharynx, it is still possible for the client to cough or vomit enteral formula into the oral cavity. Consequently, the nurse should strive to prevent aspiration by elevating the head of the bed prior to initiating the feeding. Incorrect Answers: A. Although cold enteral formula could cause cramping, it is not necessary to warm the feeding prior to administration. The formula should be at room temperature to improve the client's tolerance of gastrostomy feedings. Also, warming the formula in a microwave oven can cause uneven heat distribution and excessive heat; therefore, it is not a safe way to warm enteral feedings. C. The nurse should flush the tube with water prior to initiating the feeding to ensure the patency of the tube. D. Due to the acidity of gastric secretions, the pH of gastric contents should be below 4 to indicate proper placement of the gastrostomy tube. A pH above 4 suggests that the end of the tube is not in the stomach.
A nurse is changing the bed linens for a client who is on bed rest. Which of the following actions should the nurse perform? A. Place the soiled linens on the chair while making the bed B. Hold the linens away from the body and clothing C. Place the linens on the floor until a linen bag is available D. Shake the clean linens to unfold
Correct Answer: B. Hold the linens away from the body and clothing The nurse should hold the linens away from the body and clothing to prevent soiling or the transfer of microorganisms. The microorganisms present on the nurse's clothing can expose other clients to microorganisms. Incorrect Answers: A. The nurse should place the soiled linens in a linen bag immediately after removing the linen from the bed to prevent the spread of microorganisms on surfaces within the client's room and to minimize exposure to personnel. C. Soiled linen is contaminated with microorganisms and will further contaminate the floor and attract any microorganisms present on the floor, which places the nurse and the client at risk of infection. D. Opening linens by shaking them causes movement of air. Air currents can carry dust and spread microorganisms throughout the room, which places the client and the nurse at risk of infection.
A nurse is preparing to insert an indwelling urinary catheter for a male client. Which of the following locations should the nurse secure the urinary catheter tubing? A. Lateral thigh B. Lower abdomen C. Mid-abdominal region D. Medial thigh
Correct Answer: B. Lower abdomen After inserting an indwelling urinary catheter, the nurse should secure the catheter tubing to the client's upper thigh or lower abdomen, by using adhesive tape or catheter securement device. This location will decrease tension and trauma to the urethra. Incorrect Answers: A. Securing the indwelling urinary catheter tubing to the client's lateral or outside thigh can create tension on the client's urethra which can cause trauma and injury. C. Securing the indwelling urinary catheter tubing to the client's mid-abdominal region can create tension on the client's urethra and does not allow for the downward flow of urine via gravity into the drainage bag. D. Securing the indwelling urinary catheter tubing to the client's medial or mid-thigh area can create tension on the client's urethra which can cause trauma and injury.
A nurse is planning an in-service training session about nutrition. Which of the following pieces of information should the nurse include? A. Fat breaks down into amino acids. B. Protein serves as an energy source when other sources are inadequate. C. Glucose breaks down into ammonia. D. Carbohydrates provide 9 cal/g of energy.
Correct Answer: B. Protein serves as an energy source when other sources are inadequate. Protein is used as an energy source for the body when carbohydrates and fat stores are unavailable or depleted. Incorrect Answers: A. Protein breaks down into amino acids. C. Protein breaks down into ammonia. Glucose does not produce any products of metabolism. D. Carbohydrates provide 4 cal/g of energy. Fat provides 9 cal/g of energy.
A nurse is talking with the parent of a preschool-aged child who tells the nurse, "My child has suddenly become disinterested in certain foods." Which of the following statements should the nurse make? A. "During this phase, feed your child anything that she will eat." B. "Increase the amount of calories and water your child consumes." C. "Keep a diary of the foods your child eats each day." D. "Provide a large variety of fruit juices for your child to choose from."
Correct Answer: C. "Keep a diary of the foods your child eats each day." The nurse should encourage the parent to keep a diary of the foods the child eats throughout the day for 1 week. This can help the parent realize that the child may be eating better than expected. Evidence suggests that children can self-regulate their caloric intake. When they eat less at a meal, they can compensate by eating more at another meal or by having a snack. Incorrect Answers: A. The nurse should inform the parent that children's dietary habits can change from day to day. It is important to feed the child healthy foods and focus on the quality of food rather than the quantity of food during this time. B. The nurse should inform the client that calorie and fluid requirements decrease slightly in a preschool-aged child. The nurse should not promote an increase of calories and water in the child's diet. D. The nurse should inform the parent that excessive consumption of sweetened beverages, including fruit juices, can be associated with adverse health effects such as dental caries, obesity, and metabolic syndrome.
A nurse is providing discharge teaching for a client who has type 2 diabetes mellitus and will be caring for herself at home. The client expresses concerns about preparing an appropriate diet for her diabetes due to her cultural beliefs and preferences. Which of the following responses should the nurse offer? A. "The home health dietitian will visit and help you learn to cook all over again." B. "The dietitian will give you a list of foods and dietary choices to keep your diabetes under control." C. "The dietitian will help you choose foods you are used to that also meet your health needs." D. "It may be difficult, but I know you can change your eating and cooking habits with some help from the dietitian."
Correct Answer: C. "The dietitian will help you choose foods you are used to that also meet your health needs." This response shows respect for the client's food preferences and cultural needs by offering choices from among the client's usual foods. Incorrect Answers: A. Telling the client she should learn to cook all over again does not show sensitivity to the client's cultural needs. It implies a judgment that the client's cooking is substandard or unacceptable. B. Giving the client a standard list of foods and dietary choices does not show sensitivity to the client's cultural needs. It implies that replacing the client's cultural food preferences is the only therapeutic option. D. Telling the client she will need to change her eating and cooking habits does not show sensitivity to the client's cultural needs. It implies a judgment that the client's eating and cooking habits are substandard or unacceptable.
A nurse is providing teaching to a client regarding protein intake. Which of the following foods should the nurse include as an example of an incomplete protein? A. Eggs B. Soybeans C. Lentils D. Yogurt
Correct Answer: C. Lentils Incomplete proteins are missing 1 or more of the essential amino acids necessary for the synthesis of protein in the body. Examples of incomplete proteins include lentils, vegetables, grains, nuts, and seeds. Incorrect Answers: A. B. D. Complete proteins such as eggs, soybeans, and yogurt contain all of the essential amino acids necessary for the synthesis of protein in the body.
A nurse is preparing to administer a tap water enema to a client. Which of the following actions should the nurse take? A. Raise the enema bag if the client experiences cramping B. Lubricate 2.54 cm (1 in) of the tip of the rectal tube prior to insertion C. Place the client in a left Sims' position D. Don sterile gloves prior to the procedure
Correct Answer: C. Place the client in a left Sims' position The nurse should place the client into a left Sims' position for the insertion of an enema. This left lateral position facilitates the flow of the enema solution into the sigmoid and descending colon. The anus is exposed by flexing the right leg. Incorrect Answers: A. The nurse should administer the fluids slowly and lower the container for a client who experiences fullness or pain during the administration of the enema. B. The nurse should lubricate 5.08 cm (2 in) of the tip rectal tube prior to insertion. D. The nurse should don clean gloves to perform an enema procedure for a client.
A nurse is caring for a client who had a mastectomy and has a self-suction drainage evacuator in place. Which of the following actions should the nurse take to ensure proper operation of the device? A. Irrigate the tubing with sterile normal water once during each shift. B. Cleanse the opening with soap and water after emptying. C. Maintain the tubing above the level of the surgical incision. D. Collapse the device to remove air after emptying.
Correct Answer: D The nurse should collapse the device to remove air after emptying the contents periodically. This will create enough suction to pull fluid exudate into the collection area of the device. Incorrect Answers: A. The nurse should keep the diaphragm of the device compressed to maintain suction and prevent clotting of sanguineous drainage. This drainage system is not made for irrigating. B. The nurse should cleanse the drain opening with an alcohol wipe after opening it to decrease the entry of microorganisms. C. The nurse should maintain the drainage tubing below the level of the incision to enhance drainage.
A nurse is caring for a client who is unstable and has vital signs measured every 15 minutes by an electronic blood pressure machine. The nurse notices the machine begins to measure the blood pressure at varied intervals, and the readings are inconsistent. Which of the following actions should the nurse take? A. Turn on the machine every 15 min to measure the client's blood pressure. B. Record only the blood pressure readings needed for 15-min intervals. C. Obtain manual and automatic readings and compare them. D. Disconnect the machine and measure the blood pressure manually every 15 min.
Correct Answer: D. Disconnect the machine and measure the blood pressure manually every 15 min. If the nurse questions the reliability of the monitoring equipment, a manual process should be used. Also, malfunctioning equipment can pose a safety risk for the client, so it must be tagged and removed. Incorrect Answers: A. Because the measurements and operation of the machine appear questionable, operating the equipment differently cannot ensure the accuracy of the readings. The nurse should tag the machine and remove it from use. B. Although the equipment is obtaining blood pressure readings, the increased measurements and dissimilar results suggest that the machine is malfunctioning. Thus, all the readings are possibly inaccurate. The nurse should tag the machine and remove it from use. C. Although this option appears to provide a means of checking the machine, it is not operating correctly, which already suggests that the accuracy of the readings is questionable. The nurse should tag the machine and remove it from use.
A nurse is evaluating a client's use of crutches. The nurse should identify that which of the following actions by the client indicates safe usage of this equipment? A. The client places a crutch on each side when assuming a sitting position. B. The client moves the unaffected leg onto a step first when descending stairs. C. The client places weight on the axillae when walking. D. The client has slightly flexed elbows when ambulating with the crutches.
Correct Answer: D. The client has slightly flexed elbows when ambulating with the crutches. The client should have slightly flexed elbows when ambulating with crutches. This allows the client to bear weight on the hands and not on the axillae. Incorrect Answers: A. The client should place the crutches together in a hand and use the other hand to grasp the arm of the chair. B. The client should move the crutches onto a step first when descending stairs, followed by the affected leg. C. The client should avoid placing weight on the axillae when walking. Continual pressure on the axillae can cause damage to the radial nerve, which can lead to crutch palsy or weakness of the muscles of the forearm, wrist, and hand.