N332: Fundamentals Module 2

A nurse is discussing computerized provider order entry systems with staff. Which of the following statements from a staff member indicates an understanding of a CPOE system?

"CPOE systems can increase the speed of care delivery"

A nurse is evaluating an older adult client for an alteration in orientation. Which of the following questions should the nurse ask the client?

"Can you tell me what month it is?"

A nurse is reviewing the concepts of central sleep apnea with a colleague. Which of the following statements by the colleague indicates an understanding of central sleep apnea?

"Common causes of sleep apnea are opioid overdose and congestive heart failure."

A nurse is providing Information to a client about what may happen if their urinary tract infection (UTI) is not treated. Which of the following statements by the client indicates an understanding of the information?

"I can develop a kidney infection called pyelonephritis"

A nurse is teaching a client about foods that can irritate the bladder. Which of the following statements by the client indicates an understanding of the teaching ?

"I should avoid fruits that are acidic."

An employee health nurse is providing teaching about sleep promotion to a group of newly licensed nurses. Which of the following statements should the nurse include?

"If you do not fall asleep within 20 minutes of lying down, go to another room and listen to soft music."

A nurse is educating a client about a new temporary ileostomy. Which of the following statements by the client indicates an understanding of the teaching?

"My ileostomy is allowing my colon time to heal from the surgery."

A nurse is providing postoperative Instructions for a client who had kidney stone removal and placement of a nephrostomy tube. Which of the following statements by the client indicates an understanding of the instructions?

"This tube is only temporary"

A nurse is planning to obtain a urinary specimen from a client's closed urinary system. Identify the correct sequence of steps that the nurse should take.

1. Wipe the port with an alcohol swab or agency specified antiseptic. 2. Attach a syringe to the collection port of the indwelling catheter. 3. Withdraw 3 to 30 ml of urine. 4. Transfer the urine to a sterile specimen container.5. Transport the specimen to the lab.

A nurse is administer an enema with sodium polystyrene sulfonate to an adult client who has hyperkalemia. To which of the following lengths should the nurse insert the rectal tube.

7.5 cm to 10 cm (3-4 in)

A nurse is caring for a group of newly admitted clients. For which of the following clients should the nurse suspect to receive a prescription for urinary catheterization?

A client who is in the ICU for a GI bleed.

A nurse is reviewing documentation principals with a group of newly hired assistive personnel (AP). Which of the following should the nurse include?

A nurse who delegates a task to an AP will review the charting for that task

A nurse is discussing problem-oriented medical records with a group of newly licensed nurses. Which of the following information should the nurse include?

A problem-oriented medical record uses progress notes, which promotes information sharing among members of the interdisciplinary team.

A nurse obtains a capillary blood glucose result of 180mg/dL from a client who is diabetes mellitus. Which of the following actions should the nurse take?

Administer insulin according to the patients sliding scale orders

A nurse is preparing to administer an oil retention enema to a client who has constipation. The nurse should instruct the client to retain the solution for which of the following durations?

At least 30 min

A nurse is preparing to administer morphine 15 mg PO every 4 hr PRN pain for a client who has a new prescription. By which of the following routes should the nurse plan to administer the medication?

By mouth

A nurse is assessing a client's vital signs. while counting the number of respirations. which of the following information should the nurse collect?

Characteristics of respirations

A nurse is caring for a client who reports occasionally having dark, tea-colored urine at home. The nurse identifies that which of the following activities can contribute to this finding?

Consuming alcohol

A nurse is preparing to remove a client's indwelling urinary catheter. Which of the following actions should the nurse take?

Deflate the balloon completely before removal.

A nurse is preparing to collect a urine sample for urinalysis using a reagent strip. The nurse should Identify that the reagent strip can detect substances that are consistent with which of the following conditions?

Diabetes

A nurse is inspecting the anterior chest of a client. Which of the findings should the nurse report to the provider?

Distended veins in one breast

A nurse is caring for a client with suspected dehydration. For which of the following findings should the nurse monitor this client?

Dry mucous membranes

A nurse is caring for a client who has a new prescription for a non-benzodiazepine hypnotic to promote sleep. For which of the following adverse effects should the nurse monitor the client?

Hallucinations

A nurse is planning care for a client who has a new colostomy. Which of the following complications should the nurse plan to monitor for?

Hernia

A nurse is reviewing the medical record of a client who has persistent diarrhea. Which of the following findings should the nurse identify as risk factors ? (Select all that apply.)

History of IBS, Consumes large amounts of dairy in their diet, Currently taking antibiotics for an infection

A nurse is contributing to a presentation about hypersomnia. Which of the following information should the nurse recommend including in the presentation?

Hypersomnia does not improve with increased sleep.

A nurse is caring for a client who has narcolepsy (NT1) with cataplexy. The nurse should identify that this condition is caused by a lack of which of the following hormones?

Hypocretin

A nurse is reviewing the plan of care for a client who was admitted with insomnia and recent weight gain. Which of the following is a benefit of increased sleep that could help prevent further weight gain for the client?

Increased leptin production

A nurse is preparing to assess the status of a client's upper extremities. Which of the following actions should the nurse take?

Inspect the condition of each fingernail, Compare the amplitude of the radial pulses bilaterally, Palpate the shoulder, elbow, wrist, and finger joints

A nurse is performing an assessment of a client's lower extremities. Which of the following actions should the nurse include in this assessment?

Inspect the pattern of hair distribution.

A nurse is caring for a client who has constipation and requires an enema. Which of the following actions should the nurse take when administering the enema solution?

Instruct the client to lie on their left side with their right leg pulled up to their chest.

A nurse is assessing a client's neck. Which of the following should the nurse ask the client to perform during the assessment?

Instruct the client to swallow, Apply downward pressure and ask the client to shrug their shoulders, Request the client move their head forward and backward and then side to side.

A nurse is caring for an older adult client who is experiencing urinary leakage. Which of the following is an expected age-related change that can contribute to this occurrence ?

Loss of bladder tone

A nurse is administering a return-flow enema to a client. After instilling 100 mL of enema fluid, which of the following actions should the nurse take?

Lower the container to allow the solution to flow back out.

While a nurse is administering a cleansing enema, the client reports abdominal cramping. Which of the following actions should the nurse take?

Lower the enema fluid container.

A nurse is an outpatient setting is performing a head-to-toe assessment on a client. Which of the following should the nurse inspect when performing a general survey of the client?

Nutritional status, Hygiene, Posture

A nurse is assessing a client's posterior and lateral chest. Which of the following actions should the nurse take?

Observe for the use of accessory muscles during inspiration

A nurse is teaching a client about home collection of a stool specimen for fecal occult blood testing. Which of the following instructions should the nurse include?

Obtain specimens from three different stools

A nurse is caring for an older client who reports that they wake up frequently during the night. The nurse should identify that which of the following is a characteristic of older adult sleep patterns that might explain the client's frequent awakenings?

Older adults tend to spend more time in stage 2 sleep.

A nurse is preparing an assessment on a client who reports ear pain. Which of the following actions should the nurse take?

Palpate the mastoid area for pain

A nurse is caring for a client who has a colostomy and does not wear a colostomy pouch. Which of the following actions should the nurse anticipate performing on this client to maintain expected bowel function?

Perform colostomy irrigation

A charge nurse is reviewing characteristics of electronic documentation with staff at a providers office. Which of the following characteristics should the charge nurse plan to include?

Reduces medical errors, makes clients medical history more easily available, increases accuracy of coding procedures

A nurse is assessing a client's radial pulse rate. Which of the following information should the nurse collect while performing this action?

Regularity of the pulse, Strength of the pulse

A client who is postoperative is experiencing abdominal distention and is having difficulty expelling flatus. The nurse should expect the provider to prescribe which of the following types of enemas?

Return Flow

A nurse is caring for a client who has a stage III pressure injury on the sacral area. Which of the following actions should the nurse take when obtaining a wound culture specimen from the pressure injury?

Rotate a sterile swab in the area of drainage

A nurse caring for a group of clients in an ambulatory care clinic is collecting urine for several prescribed diagnostic tests. For which of the following tests is a random sample voided into a clean cup appropriate.

Routine urinalysis

A nurse is collecting a blood specimen for a culture from the client. Which of the following actions should the nurse take?

Rub the clients arm at the selected site prior to venipuncture.

A nurse manager is reviewing the documentation of for newly licensed nurses. Which of the following medication entries should the nurse identify as being written correctly?

Synthroid 100 mg PO every morning ac

A nurse is teaching a newly licensed nurse about the development of dreams. The nurse should include that which of the following areas of the brain transmits the sensory data that is used to develop dreams?

Thalamus

A nurse is discussing the history of electronic health records (EHRs) during a staff in-service. The nurse should identify that which of the following agencies advocated for nationwide use of EHRs.

The Institute of Medicine (IoM)

A nurse is caring for a client who needs to be awakened for the administration of an oral medication. Which of the following findings should indicate to the nurse that the client was in stage 3 of the sleep cycle when awakened?

The client experiences mental cloudiness for 30 to 60 min.

A nurse is caring for a group of clients who are at risk for an alteration in urinary elimination of the following groups should the nurse identify as being at an increased risk? (Select all that apply.)

Uncircumcised infants, School-age children, Older adults

A nurse is caring for a client who has a stone in the right ureter that is obstructing the flow of urineWhich of the following urinary diversions should the nurse anticipate the client will need?

Ureteral stent

A nurse is caring for a client who takes an over-the-counter (OTC) sleep aid medication every evening. Which of the following findings should the nurse identify as potential adverse effect of OTC sleep aid medication?

Urinary retention

A nurse planning care for a client who has an order for urinalysis. Which of the following tests should the nurse anticipate being ordered if the presence of white blood cells is detected on urinalysis?

Urine culture

A nurse is talking with a client about the electronic health record at the facility. Which of the following client statements indicates an understanding of EHRs?

"I will be able to track my health information"

A nurse manager is conducting an in service about the physiological functions of sleep for a group of staff nurses. Which of the following statements by one of the nurses indicates an understanding of the teaching?

"The brain and neurons continue to communicate with each other during sleep to remove toxins that built up in the brain while awake."

A nurse is assessing a client who reports difficulty staying awake during the day and experiencing involuntary episodes of lost muscle tone. The nurse should identify that these are manifestations of which of the following conditions?

(NT1)

A nurse is preparing to care for a group of clients in an acute care setting. Which of the following assessments should the nurse plan to perform on every client?

Auscultate bowel sounds prior to palpating.

A nurse is preparing to insert an indwelling urinary catheter. Which of the following actions should the nurse instruct the client to perform during the insertion procedure?

Bear down

A newly licensed nurse is orienting to a facility's documentation process. The facility requires staff to only document variations from an expected set of findings when performing a physical assessment. The nurse should identify this system as which of the following documentation methods?

Charting by exception

A nurse is assessing a client's indwelling urinary catheter drainage at the end of the shift and notes the output is considerably less than the fluid intake. Which of the following actions should the nurse take first?

Check the catheter for kinks.

A nurse is teaching a newly licensed nurse about urinary retention. Which of the following clients should the nurse include as having an increased risk for this condition ?

Client who has an enlarged prostate

A nurse is teaching a about diagnostic urinary testing. Which of the following should the nurse include in the teaching about cystometric testing?

Cystometric testing measures bladder capacity, pressure, and final capacity when the urge to urinate begins.

A nurse is preparing to conduct a head-to-toe assessment on a client in an outpatient setting. At which of the following times should the nurse plan to collect information about the client's general appearance?

During an interview about the client's health history is correct, When introducing themselves to the client is correct, While collecting the client's vital signs is correct.

A nurse is preparing to Insert a nasogastric tube into a client for decompression. Which of the following actions should the nurse perform first?

Ensure the client is in a sitting position.

A nurse is discussing legal regulations regarding medical records with a newly hired assistive personnel (AP). Which of the following information should the nurse include?

Facilities can establish their own rules for documentation methods

A nurse is educating a client who has paraplegia about urinary catheter use. Which of the following catheter types should the nurse include the teaching to help facilitate urinary elimination for this client?

Intermittent catheter

A nurse is applying a condom catheter for a client who is uncircumcised. Which of the following actions should the nurse take?

Leave a space between the penis and sheath portion tip.

A nurse is preparing an adult client for an enema. The nurse should assist the client into which of the following positions?

Left lateral with the right leg flexed.

A nurse is caring for a client who has been suspected urinary tract infection (UTI). Which of the following urinalysis results should the nurse identify as a manifestation of a UTI?

Leukocyte esterase

A nurse is preparing a male client for intermittent urethral catheterization. Which of the following actions should the nurse take?

Lift the penis perpendicular to the body.

A nurse is preparing to administer a cleansing enema to a client who has poor sphincter control. Which of the following actions should the nurse take?

Place the client in the dorsal recumbent position on a bedpan.

A nurse is teaching a client about collecting stool specimens for fecal occult blood testing. Which of the following should the nurse instruct the client to avoid before and during the testing period.

Poultry

A charge nurse is reviewing soap documentation with a group of newly licensed nurses. Which of the following chart entries should the nurse include as an example of objective data?

Rebound tenderness noted in RLQ of the abdomen

A nurse is caring for a client who has a history of migraines. The client tells the nurse, "I have not been sleeping well. My migraine headaches have returned after not having one for over a year." The nurse should identify that which of the following are potential contributing factors to the client's migraines? (Select all that apply)

Sleep deprivation, sensory overload

A nurse is discussing the stages of the sleep cycle with a client. The nurse should include that the immune system is strengthened and tissues and bones are repaired during which of the following stages of the sleep cycle?

Stage 3

A nurse is documenting information in a clients chart and makes the entry quotation mark client reports "abdominal pain on exertion". Which of the following documentation format describes this entry?

The S in soap

A nurse is caring for a client who is receiving antibiotic treatment for a urinary tract infection and experiencing diarrhea. Which of the following should the nurse identify as a potential cause of the diarrhea?

The antibiotic eliminates the healthy gastrointestinal bacteria allowing bacteria grow

A nurse is reviewing the primary function of the urinary tract with a group of newly licensed nurses. Which of the following information should the nurse include?

The urinary tract eliminates waste and excess fluid from the body.

A nurse is preparing to administer the first of two large-volume, cleansing enemas prescribed for a client in preparation for a diagnostic procedure. Which of the following actions should the nurse take?

Warm the enema solution prior to installation

A nurse caring for a client who has diabetes mellitus is having difficulty obtaining a capillary fingerstick blood sample for point of care blood glucose testing. Which of the following actions should the nurse take to help increase blood flow to the clients fingers

Wrap the finger in a warm cloth