NSG 486- Fundamentals Final

A nurse is caring for a client who has acute renal failure. Which of the following assessments provides the most accurate measure of the client's fluid status? A. Daily weight B. Blood pressure C. Specific gravity D. Intake and output

*A. A gain or loss of 1 kg indicates a gain or loss of 1 L of fluid* B. Can indicate a client's fluid gains or losses, but not most accurate C. Reflects the kidney's ability to concentrate urine D. Reflects a client's fluid status but is not the most accurate

A nurse is planning to assess the abdomen of a client who reports feeling bloated for several weeks. Which of the following methods of assessment should the nurse use first? A. Inspection B. Auscultation C. Percussion D. Palpation

*A. Should assess before having direct contact with client* B. The nurse should auscultate before percussion and palpation because they can both stimulate peristalsis C. This can cause pain and peristalsis D. This can cause pain and peristalsis

A nurse in a provider's office is assessing a client who has heart failure. The client has gained weight since her last visit and her ankles are edematous. Which of the following findings by the nurse is another clinical manifestation of fluid volume excess? A. Sunken eye balls B. Hypotension C. Poor skin turgor D. Bounding pulse

A. Fluid volume deficit B. Fluid volume deficit C. Fluid volume deficit *D. This is an expected finding*

A nurse is providing discharge teaching to a client who is recovering from lunch 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

A. Moderate-intensity B. High-intensity C. Moderate-intensity *D. Low-intensity*

A nurse in a long-term care facility is admitting a client who is incontinent and smells strongly of urine. His partner, who has been caring for him at home, is embarrassed and apologizes for the smell. Which of the following responses should the nurse make? A. "A lot of clients who are cared for at home have the same problem" B. "Don't worry about it. He will get a bath, and that will take care of the odor" C. "It must be difficult to care for someone who is confined to bed" D. "When was the last time that he had a bath?"

A. This is judgmental B. This devalues her feelings and her concern *C. This response addresses the feelings of the partner by reflecting on her feelings* D. This is judgmental

A nurse is explaining the use of written consent form to a newly-licensed nurse. The nurse should ensure that a written consent form has been signed by which of the following clients? A. A client who has a prescription for a transfusion of packed RBCs B. A client who is being transported for a radiography of the kidneys, ureters, and bladder C. A client who has a prescription for a TB skin test D. A client who has a distended bladder and need urinary catheterization

*A. This carries risk, so the client must sign a consent form prior to* B. A general consent form allows for diagnostic testing C. Implied consent is given when the client cooperates through actions, like holding the arm out D. Implied consent is given when the client cooperates, like positioning herself to allow the nurse for perform the procedure

A nurse is caring for a client who is receiving IV therapy via a peripheral catheter. The nurse should identify that which of the following findings is an indication of infiltration? A. Redness at the infusion site B. Edema at the infusion site C. Warmth at the infusion site D. Oozing of blood at the infusion site

A. This could indicate phlebitis or infection *B. Edema due to fluid entering subcutaneous tissue* C. This could indicate phlebitis or infection D. This could indicate that the IV system is not intact

A nurse is caring for a client who is post-op following abdominal surgery. Which of the following actions should the nurse take first after discovering that the client's wound has eviscerated? A. Cover the incision with a moist, sterile dressing B. Have the client lie on his back with his knees flexed C. Call the client's surgeon D. Reassure the client

*A. This will protect the client the most* B. This can be used to reduce pressure on the incision, but not the first step C. The surgeon should be notified, but not first D. The nurse should tend to the client's emotional needs, but not first

A client who reports shortness of breath requests her nurse's help in changing positions. After repositioning the client, which of the following actions should the nurse take next? A. Encourage the client to take deep breaths B. Observe the rate, depth, and character of the client's respirations C. Prepare to administer oxygen D. Give the client a back rub to help her relax

A. This can help increase the client's intake of oxygen, but something else should be done first *B. Assessment will provide knowledge to help the nurse make an appropriate decision* C. Preparing oxygen is important, but something else should be done first D. This can help reduce dyspnea, but something else should be done first

A nurse is using the I-SBAR communication tool to provide the client's provider with information about the client. The nurse should convey the client's pain status in which portion of the report? A. Assessment B. Background C. Situation D. Recommendation

*A. This includes vital signs, pain assessment, and changes in assessment findings* B. This consists of pertinent medical history, laboratory findings, allergies, and code status C. Problems the client is experiencing D. Recommendations of treatment

A nurse is caring for a client who, while sitting in a chair, starts to experience a seizure. Which of the following actions should the nurse take? A. Place a padded tongue blade in the client's mouth B. Lower the client to the floor and place a pad under the client's head C. Seek the help of a coworker and left the client back into the bed D. Use an oropharyngeal airway to keep upper airway passages open

A. This can cause injury such as broken teeth *B. This will reduce the risk of injury* C. The nurse should not attempt to lift the client during a seizure D. This can cause injury such as broke teeth

A nurse in a provider's office is collecting information from an older adult client who reports that he has been taking acetaminophen 500 mg/day for severe joint pain. The nurse should instruct the client that large doses of acetaminophen could cause which of the following adverse effects? A. Constipation B. Gastric ulcers C. Respiratory depression D. Liver damage

A. Opioid analgesics B. NSAIDs C. Opioid analgesics *D. Daily intake should be limited to less than 3-4 grams/day*

A home health nurse is planning to provide health promotion activities for a group of clients in the community. Which of the following activities is an example of the nurse promoting primary prevention? A. Teaching clients to perform self-examinations of breasts and testicles B. Educating clients about the recommended immunization schedule for adults C. Teaching clients who have DM type 1 about care of the feet D. Recommending that clients over the age of 50 have a fecal occult blood test annually

A. This is secondary prevention *B. Includes health education about disease prevention* C. This is tertiary prevention D. This is secondary prevention