fundis 1

a charge nurse is observing a newly licensed nurse nurse insert an indwelling urinary catheter for a male client. which of the following actions by the newly licensed nurse requires intervention by the charge nurse?

secures the tubing to the side rail of the client bed.

a student nurse is preparing to administer lovenox subcutaneous prophylactic to prevent deep vein thrombosis. which of the following actions should prompt the clinical instructor to intervene

select the site that has adequate fat pad size

The nurse is staffing a medical-surgical unit that is assigned most of the patients with pressure ulcers. The nurse has become competent in the care of pressure wounds and recognizes that a staged pressure ulcer that does not require a dressing is stage: A. I B. II C. III D. IV

stage 1 A.I

a nurse educator is reviewing the wound healing process with a group of nurses. the nurse educator should include in the information which of the following alternations for wound healing by secondary intention

stage 3 pressure ulcer

a nurse is caring for a client who is receiving continuous enteral feeding. which of the following nursing interventions is the highest priority when the nurse suspects aspiration of the feeding?

stop the feeding

a nurse is administering nasal decongestant drops for a client. which of the following should the nurse take?

tell the client to blow their nose before administering meds

a nurse is caring for a client in a long term care facility who is receiving enteral feeding via an ng tube, which of the following actions should the nurse take

test the ph of gastric aspirate

a nurse is administering a skin testing tuberculosis drug intadermal. what are some things nurses need to consider while administering the intradermal injection?

the angle of insertion is less than 15 degrees a small bled appears on the skin. the bevel of the needle is pointed up.

a nurse is assessing a clients ability to ambulate with crutches using a three point gait. which of the following actions should the nurse identify as a risk to clients safety?

the client places partial weight on the affected leg

a charge nurse observes a nurse administer in intermittent tube feeding via an NG tube to a client . which of the following actions should prompt the charge nurse to intervene?

the nurse allows the client to rest in a supine position during feeding.

a nurse is caring for a client who receive intermittent enteral feeding through a NG tube. before administering a feeding, the nurse should measure the gastric residual for which of the following purposes.

to confirm the placement of the NG tube

a nurse is discharging a client who came to the outpatient clinic with an ankle sprain. which of the following statements should the nurse identify as an indication that the client understands the discharge instruction?

"ill apply ice to my ankle today and tomorrow"

a nurse is caring for a client who is 2 days postoperative following an appendectomy and has type 1 diabetes mellitus. their Hemoglobin is low and BMI is 17.1. the incision is approximated and free of redness with scant serous drainage on the dressing. the nurse should recognize that the client has which of the following risk factors for impaired wound healing? (select all that apply )A. extremes in age B. chronic illness C. low hemoglobin D. malnutrition E. poor wound service

- cronic illness -low hemoglobin - malnutrition

the nurse is performing a pressure ulcer risk assessment.which risk factors predispose a client to pressure ulcer development?

- decrease ability to feel pain -discomfort - urinary incontinace

a nurse is collecting data from a client who is 3 days postoperative following abdominal surgery. the surgeon suspects an incisional wound infection and has prescribed wound culture and sensitivity. which of the following findings should the nurse expect?

- increase in incisional pain - increase WBC - fever and chills - reddened wound edges

a nurse is preparing to administer 10 units of regular insulin and 20 units of NPH insulin to a client. what sequence of events the nurse should follow?

- inspect vial for contaminants - roll NPH vial between pals hand - inject air into NPH insulin vial - inject air into regular insulin vial - add intermediate insulin to syringe - withdraw short acting insulin into syringe

the nurse is performing a pressure ulcer risk assessment. which risk factors predispose a client to pressure ulcer development?

urinary incontinence, decreased ability to feel pain or discomfort

a client feels discomfort in his pubic area. he tells the nurse he has been voiding only a little bit about every half hour. what are these clinical signs indicating?

urinary retention

a nurse accidentally stick her hand with a syringe needle after administering an IM injection to a client. which of the following actions should the nurse take first.

wash the area of the puncture thoroughly with soap and water

a nurse is delivering an enteral feeding to a client who has an NG tube in place for intermittent feedings. when the nurse pours water into the syringe after the formula is given, the client asks the nurse why the water is necessary. which of the following responses should the nurse make?

water helps clear the tube so it don't get clogged

A nurse at an extended-care facility is instructing a class of AP's about the use of assistive devices during ambulation. Which of the following should the nurse give the AP's about the clients' use of a cane?

when the client moves he should move the cane forward first

a nurse is observing a nurse performing a Mantoux tuberculin skin test for a client. which of the following actions should the nurse prompt the charge nurse to intervene.

withdrawing the needle and massage the side gently

a nurse is preparing to apply a transdermal analgesic patch. which of the following actions should the nurse plan to take?

- remove the old patch - cleanse the skin prior to procedures - apply to intact skin - document patch placement, date and time

a nurse is caring for a client who is at risk for developing pressure injury. which of the following interventions should the nurse use to help maintain the integrity of the skin?

- reposition the client every 2 hours while in bed - apply corn starch liberally to the skin after bathing - have the client sit on a gel cushion when in na chair

a nurse is preparing to transfer a client from a bed to a c hair. which of the following actions should the nurse take first?

-determine if the client can bear weight -Aligning the nurses knees with the clients knees just before the transfer

the nurse is caring for a client diagnosed with a urinary tract infection. which risk factors increase the incidence of a uti?

-poor perinea hygiene - urinary retention -having an indwelling catheter

a nurse is receiving a providers prescription for a client via telephone.which of the following actions should the nurse take to ensure accuracy?

-question any part of the order that is unclear or inappropriate -transcribe the order into the clients health recording -repeat the order back to the doctor

a nurse is preparing an in service program about preventing medical errors when transcribing a prescription. the nurse is using a dosage example of two tenths of a milligram. which of the following examples should the nurse use to show appropriate transcription of this dosage?

0.2mg

a nurse is preparing to administer penicillin Im to an adult client. which of the following Angeles should the nurse use for injection into the clients

90 degrees

a nurse is teaching a client who has strained her back muscle while preparing to move to a new apartment. which of the following instruction should the nurse take.

bend at the knee when picking up an object.

a nurse is helping an older adult client ambulate in the hallway for the first time since admission. the client has brought her standard walker from home. to ensure proper use of the waker and the safety of the client. which of the following actions should the nurse take?

check that the client lifts the walker and then places it down in front of her

when reviewing the admitting prescription the nurse notes that the dose of one medication is three times the usual dose of this medication. which of the following actions should the nurse take?

contact the doctor to question the dosage

a nurse is teaching a client how to administer medication through a percutaneous endoscopic gastrostomy (PEG) tube. which of the following instruction should the nurse include.

flush the tube before and after each medications

the patient has just been stared on enteral feeding and has developed diarrhea after being on the feeding for 2 hours. what does the nurse suspect is the most Oakley cause of diarrhea?

formula intolerance

a nurse is expecting some problems with joint stability. the doctor prescribed crutches for the client to use while still being allowed to bear weight on both legs.which os the following gait should the client be taught to use?

four point gait

a nurse is teaching a client who has hemiparesis how to use a cane. which of the following instructions should the nurse include.

hold the cane on the right side to provide support for the weaker leg.

the nurse is providing nutrition teaching to a client visiting from Korea. what must the nurse focus the teaching on for this client?

incorporating the client food preference

a nurse is assessing a client who has a pressure ulcer. the nurse should recognize which of the following findings is a manifestation of a stage 3 pressure ulcer?

necrotic subcutaneous tissue

a nurse is preparing a sterile field. which of the following actions should the nurse preform when opening a sterile pack?

open the top flap away from the body

a nurse is educating a client about urgency urinary incontinence. what is the most appropriate statement by the nurse regarding treatment is this type of incontience?

performing pelvic floor exercises three times a day

a nurse is preparing to administer the hepatitis b vaccine to a client. which of the following techniques should the nurse use to locate the deltoid muscle?

place one finger across the acromion process and measure 3 finger breadths below to the midpoint and center of the lateral aspect of the upper arm

a nurse is planning care for a client who has manifestations of c diff. which of the following actions should the nurse plan to take

place the client on contact precaution

a nurse in a long term care facility is observing assistant personnel (AP) changing the linen for a client who has Fecal incontinece. which of the following actions indicated that the AP understands the principal of infection control?

places clean linen that touched the floor in the soiled linen bag

a nurse is teaching a class about medication reconciliation. which of the following information should the nurse include in the teaching?

provide a list of the clients current medications during the change of shift report

which statement made by a 2 year old clients mother indicates that she understands how to administer her sons ear-drops

pull auricle down and back

a nurse finds an open via of morphine lying on top cabinet in a client room. which of the following actions should the nurse take?

report the discrepancy immediately

a nurse reviewing a clients health record notes a new prescription for lisinopril 10 mg orally everyday. the nurse should identify this as which of the following types pf prescription

Routine prescription.

A nurse is preparing to use the Z-track technique to administer a medication to a client. Which of the following actions should the nurse plan to take?

Aspirate for 5 to 10 seconds before injecting the meds

a nurse is administering an oral medication to an older client. the client states " the pill I always take is green. I don't take an orange pill. which of the following responses should the nurse make?

I will check your medication order again

a nurse working in an emergncy room is assessing a client who has a leg wound. the nurse noted a full thickness wound with jagged edges and muscle tissue visible. the nurse should document this as which of the following types of wounds

Laceration

the nurse is caring for a client who has nonfunctional gastrointestinal tract. which method would be appropriate for this client to receive nutrition

TPN

which statement is true regarding a standing order?

administered until dosage is changed or another medication is prescribed

what is the most important role of the nurse in preventing medication administration errors?

always follow the six rights of med administration

a client who has an indwelling catheter reports a need to urinate. which of the following actions should the nurse take?

assess that the catheter is not kinked or clogged and urine is flowing in the bag.

a client receives a wrong medication. the nurse who made the medication error should take which of the following actions

assess the client

a nurse is preparing to administer a pre packaged oral medication to a client and complete the final medication check.at which of the following times or places should the nurse perform this final check?

at the clients bedside before administration

a nurse is preparing to administer lovenox subcutaneous prophylactic to prevent deep vein thrombosis. which of the following actions should prompt the clinical instructor to intervene?

displaced the skin back to prevent medication from leaking back into subcutaneous skin and straining the skin

a charge nurse is observing a newly licensed nurse administer medication to a client. which of the following actions by the newly licensed nurse should prompt the charge nurse to intervene

documents medication administration prior to administering it .

a nurse is planning to perform a sterile dressing change for a client. which of the following actions should the nurse plan to take?

don sterile gloves to move the sterile items on the field

a nurse is administering timolol eye drops to a client who has glaucoma. which of the following actions should the nurse take?

drop prescribed amount of medication into the conjunctival sac

a nurse is admitting a client who has meningitis. which of the following types of transmission based precautions should the nurse initiate

droplet precaution