Nursing Fundamental exam 1.
A nurse follows surgical asepsis techniques for inserting an indwelling urinary catheter in a client. What is an accurate guideline for using this technique?
Hold sterile objects above waist level to prevent inadvertent contamination.
A nurse manager is teaching staff how to use a new piece of hospital equipment. Which educational setting would be most appropriate for this process?
In-service education
A nursing student is manually taking the client's blood pressure. Which step will demonstrate the correct way of inflating the blood pressure cuff?
Inflate the cuff to 30 mm Hg above reading where brachial pulse disappeared.
The nurse preparing a lecture on the history of nursing should include which international organization as the first for professional nurses?
International Council of Nurses
A nurse educator is discussing the role of nursing based on the American Nurses Association (ANA). Which statement best describes this role?
It is the role of nursing to provide a caring relationship that facilitates health and healing.
The nurse must assign a room for a client admitted with endocarditis and methicillin-resistant Staphylococcus aureus (MRSA) in the blood. A client with which diagnosis can share a room with this client?
MRSA in the wound
A nurse wishes to pursue a degree as a nurse practitioner. What is the minimal degree needed by the nurse?
Master's
A nurse needs to measure the blood pressure of a client with an electronic manometer. Which of the following advantages does an electronic manometer provide over an aneroid manometer or mercury manometer?
No stethoscope is required.
The client's plan of care is created by the nurse using which guideline for nursing practice?
Nursing process
When accessing a client's central line, a drop of the client's blood falls on the nurse's gloved hand. What is the appropriate action by the nurse?
Perform hand hygiene after removing the glove
The nurse is caring for a client with a new diagnosis of cancer, and allows the client to verbalize fears relating to how to tell the children. The nurse's intervention reflects which aspect of nursing?
art of nursing
In what time period did nursing care as we now know it begin?
18th to 19th century
The nurse is evaluating client health. Which client should the nurse determine to be exhibiting the most signs of health?
A client with a leg amputation who performs activities of daily living with a prosthesis
A nurse has applied a blood pressure cuff to a client's upper arm, positioned the stethoscope over the client's brachial artery, inflated the cuff and is now slowly releasing air from the cuff. The nurse should recognize the client's peak blood pressure when what sound is audible?
A faint, clear tapping sound
Which scenario is the best example of a nurse in the role of counselor?
A nurse allowing a crying client to verbalize fears of death
Which is an appropriately stated nursing intervention?
Ambulate 30 ft (9 m) twice a day with the assistance of a walker.
The first nursing journal owned, operated, and published by nurses was:
American Journal of Nursing
Which organization has established standards that help the nurse determine which clinical actions fall under the scope of nursing practice?
American Nurses Association
Which nursing group provides a definition and scope of practice for nursing?
American Nurses Association (ANA)
Which client presents the most significant risk factors for the development of Clostridium difficile infection?
An 81-year-old client who has been receiving multiple antibiotics for the treatment of sepsis
The nurse is caring for a client admitted with tuberculosis (TB). What would be the best action by the nurse?
Apply a nonparticulate (N-95) respirator when entering the room.
A client has tested positive for colonization with a multidrug-resistant organism (MDRO) and has been placed on contact precautions. Which actions should be included in this client's care? Select all that apply.
Arrange for the client to be housed in a single room. Use appropriate PPE.
The nurse is performing care for a client in the end stage of cancer. How can the nurse best facilitate the client and family's ability to cope? Select all that apply.
Assist the client with activities of daily living (ADLs). Assist the client and family with the preparation for end-of-life. Refer the client and family to hospice services.
A nurse is assessing the respirations of a 60-year-old female client and finds that the client's breaths are so shallow that the respirations cannot be counted. What would be the appropriate initial nursing intervention in this situation?
Auscultate the lung sounds and count respirations.
Which peripheral pulse site is generally used in emergency situations?
Carotid
When preparing to take a client's blood pressure, the nurse notes that the sphygmomanometer is visibly soiled. What is the correct action by the nurse?
Cleanse and disinfect the sphygmomanometer.
The nurse is assessing the client's blood pressure (BP) and heart rate (HR) for orthostatic hypotension. In which step should this nurse intervene because of potential danger?
Client stands at bedside, becomes pale, diaphoretic.
Which is the best example of a client-centered approach to care?
The nurse asks the client about health goals.
A nurse is following medical asepsis when caring for clients in a critical care unit. Which nursing actions follow these principles? Select all that apply.
The nurse carries soiled items away from the body. The nurse moves soiled equipment away from the body when cleaning it. The nurse cleans least soiled areas first and then moves to more soiled ones.
A nurse is caring for a client who is diagnosed with tuberculosis. Which nursing intervention promotes infection control based on nursing practice standards for safety?
The nurse places the client in a private room with monitored negative air pressure.
Which client's blood pressure best describes the condition called hypotension?
The systolic reading is below 100 and diastolic reading is below 60.
A nurse is assessing the blood pressure of a client using the Korotkoff sound technique. The nurse notes that the phase I sound disappears for 2 seconds. What should the nurse document on the progress record?
There is an auscultatory gap.
A registered nurse wishes to work as a nurse researcher. Which is true regarding nurse researchers?
They are responsible for the continued development and advancement of nursing.
A 62-year-old female client being treated for hypertension did not take her daily BP medication over the weekend because she was out of medication and the pharmacy was closed. Her average home blood pressure monitoring (HBPM) reading has been 130/82. Today her BP has been 138/90, 135/85, and 142/86. She calls the on-call nurse for her health care provider. What is the most appropriate thing for this nurse to advise this client?
To take the recommended daily dose of medication and call the health care provider if the average of her HBPM readings increase/decrease by 10, or if she has any other concerns.
During measurement of a rectal temperature, the thermometer probe should be inserted about 1.5 inches (3.8 cm) in an adult and 0.5 inches (1.3 cm) in an infant.
True
The nurse is preparing to apply a prescription ointment to the client's wound. After reviewing the image, what is the most important step for the nurse to take?
Use a sterile cotton-tipped applicator to apply the prescription to the site
A nurse is providing care to a client who has Salmonella food poisoning. The nurse understands that this pathogen was transmitted by which mechanism?
Vehicle
The RN is working with hospital administrators to transform care at their facility. Which nursing competency will be critical for the nurse to utilize?
Work effectively in interdisciplinary teams
A 70-year-old client is taking his own pulse at home. He is following the instructions provided by the nurse. He counts his pulse 62 times in one minute. What should he do next?
Write it down
When a nurse picks up a client's contaminated tissue without gloves and fails to wash the hands sufficiently, the nurse provides for the client's organisms to be spread by which type of
contact
Which nursing action best exemplifies the nurse's role in promoting health?
encouraging a group of junior high school students to engage in regular physical activity
A nurse is planning to pursue further education in the hopes of becoming an expert in geriatric nursing who carries out direct care. For which expanded career role is the nurse preparing?
Clinical nurse specialist
The nurse has admitted a client on airborne precautions onto the medical-surgical unit. When the client asks, "When will these airborne precautions be removed?" what is the appropriate nursing response?
"When your sputum culture is negative."
The home care nurse notices that the client only has a glass thermometer. What is the best response by the nurse?
"Would you consider using a digital thermometer?"
The nurse observes a member of the nursing assistive personnel who is removing personal protective equipment (PPE) in the client's room, as seen in the image above. What education should the nurse provide to this member of the care team?
"Avoid touching the outside of your gown when removing it."
The nurse is caring for a client who ascribes to the theory of animism. When attempting to explain this theory to other staff members, the nurse should state:
"Everything in nature is alive with invisible forces."
A pediatric client's caregiver states, "I will never give my child vaccinations." What is the priority nursing response?
"Help me understand your thoughts about vaccinations."
The nurse is educating a client with human immunodeficiency virus (HIV) about ways the virus can be transmitted. Which statements made by the client demonstrates the education provided was effective? Select all that apply.
"If someone is exposed to my blood, I may transmit the virus to him or her." "I may transmit the virus to my child during pregnancy and childbirth." "I may transmit the virus if I share needles with another person."
The registered nurse is teaching a community health class about illness prevention. Which statement reflects understanding of this concept?
"It is important to enroll in a smoking cessation class."
The nurse is attempting to provide anticipatory guidance for the parents of an 18-month-old child. Which statement would be best for the nurse to make?
"Keep all medications in a locked cabinet."
When taking the client's temperature, the student nurse will require further education when they state:
"The axillary route is the most accurate of all routes."
The nurse is donning a pair of sterile gloves. The nurse correctly dons the first glove, but inadvertently inserts the thumb and index finger into the thumb hole of the second glove. The glove remains intact. Which action is most appropriate?
Continue to don the glove, then use the other gloved hand to carefully insert the finger into the proper hole.
The nurse is setting up a sterile field to perform a catheterization when the client touches the end of the sterile field. What would be the nurse's next appropriate action?
Discard the sterile field and the supplies and start over.
Which best exemplifies the role of the nurse as educator?
Discussing side effects of a medication with a client
The nurse has finished caring for a client on contact precautions. Which nursing action regarding the stethoscope used to auscultate this client's lungs and bowel sounds is appropriate?
Disinfect it with alcohol swabs.
Which statement describes diastolic blood pressure?
During ventricular relaxation, blood pressure is due to elastic recoil of the vessels.
The nurse is performing an extensive dressing change on a client with burns. The nurse explains each step as it is being performed. The nurse is acting in which role by providing explanation of each step?
Educator
The nursing process includes step(s)? Select all that apply.
Evaluate Plan Assess Implement
A client is distraught because a recent computed tomography (CT) scan shows that the client's colon cancer has metastasized to the lungs. Which nursing aim should the nurse prioritize in the immediate care of this client?
Facilitating coping
A person's core body temperature is highest in the early morning and lowest in the late afternoon.
False
Which mask should the nurse don when caring for a client with tuberculosis?
Filtered respirator
The nurse is caring for a client who has active tuberculosis and is under airborne precautions. The health care provider prescribes a computed tomography (CT) examination of the chest. Which action by the nurse is appropriate?
Place a surgical mask on the client and transport to the CT department at the specified time.
What is the primary goal of the observable action associated with the removal of contaminated gloves?
Prevent contamination of ungloved hand
A nurse is assessing the pulse volume of a client with influenza. The nurse notes that the client has a thready pulse. Which of the following is a description of a thready pulse?
Pulse is felt with difficulty and disappears with slight pressure.
Which nursing intervention would be most appropriate for a new mother that calls the nursery for help with breastfeeding?
Refer the mother for a home care visit.
A client who has been taught to monitor her pulse calls the nurse because she is having difficulty feeling it strongly enough to count. She states that she takes her pulse before taking her cardiac medication. She sits down with her nondominant arm on a firm service, palm up. She uses her three fingers to feel just below the wrist on the side closest to the body. She does not press hard and she has a watch with a second hand to use to count it, but she has a very difficult time feeling it. What does the nurse recognize that she is doing wrong?
She should place her three fingers just below the wrist on the outside of the arm with the palm
The nurse conducts a home safety assessment for a client. Which statement best explains the standard of care being implemented?
The RN promotes a safe environment.
A nurse is providing care for clients in a long-term care facility. What should be the central focus of this care?
The client receiving the care
When administering beta blocker medications, the physician adds an order to hold medication when the client is bradycardic. Which statement explains this order?
The client's pulse rate is below 60 beats per minute.
The nurse is teaching a new nurse about preparing a sterile field. Which action made by the new nurse would indicate further teaching is required?
The new nurse touches 1.5 in. (4 cm) from the outer edges.
A nurse records a pulse rate of 170 beats/min on a client's electronic health record. For which client would this be considered a normal assessment finding?
a healthy newborn infant
Clients demonstrating apnea have what?
a temporary cessation of breathing
The nurse is caring for a client with tuberculosis. Which precautions will the nurse select for this client?
airborne
The nurse is caring for an older adult with pulmonary tuberculosis. Which precautions will the nurse begin?
airborne
The nurse caring for clients at an outpatient clinic determines that which client is at greatest risk for infection?
an 80-year-old woman
The nurse is preparing to administer a medication that the client takes to treat a cardiac dysrhythmia. Which site should the nurse use to assess pulse in this client?
apical
The nurse is preparing to measure an adult's radial pulse using a Doppler device. Place the following steps of the procedure in the correct order.
apply conducting gel to the site where the pulse will be auscultated place the Doppler probe tip in the gel adjust the volume of the device as needed maneuver the tip of the Doppler probe over the area until the pulse is heard count the number of heartbeats for 1 full minute wipe the gel off of the client's skin
The nurse assesses that a client is shivering. Which intervention is most appropriate to prevent further stress on the body?
applying a blanket
The nurse graduated several years ago from a 2-year nursing program at a community college near the home city. Recently, the nurse has considered moving from providing direct client care into an administrative role, but recognizes the need for further education to be considered for such a position. The nurse most likely possesses which nursing qualification?
associate degree
An ultrasonic Doppler is used for:
auscultating a pulse that is difficult to palpate.
A client suffers from bloody diarrhea after eating contaminated food at a local restaurant. The client has been infected with a(an):
bacteria.
The nurse is caring for a client with tuberculosis. The prior shift's nurse has placed the client in droplet precautions. Which is the appropriate nursing action?
change to airborne precautions
A nurse is assessing an apical pulse on a cardiac client. The client is taking digoxin. The nurse can anticipate that the digoxin will:
decrease the apical pulse.
The nurse is preparing to assess a client's oral temperature. The nurse should plan to place the thermometer probe in which area of the client's mouth?
deep in the posterior sublingual pocket
An acute medicine unit of a hospital currently has a number of clients who have tested positive for methicillin-resistant Staphylococcus aureus (MRSA). Which measures should the nursing staff prioritize in preventing the spread of MRSA to clients who are currently MRSA-negative?
diligent handwashing practices
Which personal protective equipment (PPE) should the nurse don to enter the room of a client who is diagnosed with Clostridium difficile?
gown and gloves
The nurse is caring for a client who developed pneumonia while hospitalized. How will the nurse document this condition?
health care-associated infection (HCAI)
Upon assessing a client who is hemorrhaging, the nurse is most likely to assess which compensatory change in vital signs?
increased pulse rate
The temperature is 102°F (39°C) during a heat wave. The nurse can expect admissions to the emergency room to present with:
increased temperature.
A prospective nursing student desires a career that will allow the opportunity to provide client care and to assist professional nurses with routine technical procedures. The prospective student needs to be employed in a full-time position quickly due to economic hardship. What type of nursing program would best suit this student?
licensed or vocational nursing program
In the role of entrepreneur, the nurse's primary responsibility is:
managing a health-related business.
The nurse is caring for a client who has been hospitalized and placed in airborne precautions for a week. Which nursing intervention is appropriate to provide sensory stimulation?
move the bed and furnishings to a different place in the room
The nurse who is caring for a client in contact isolation is preparing to conduct an assessment. Which stethoscope will the nurse choose to auscultate the client's bowel sounds?
one that remains in the client's room
The nurse places a client experiencing labored breathing in an upright position. The nurse notes that the client is able to breathe more easily in this upright position and documents this condition on the chart as:
orthopnea
The nurse is recovering from a very mild upper respiratory infection with no fever. The nurse is assigned to care for four clients. What is the appropriate nursing action?
perform meticulous hand hygiene and don a new mask with each client encounter
A nurse needs to assess the temperature of a client with high fever. Which site will most closely reflect core body temperature of the client?
rectum
The nurse observes an unlicensed assistive personnel (UAP) collecting a urine specimen from a client with Staphylococcus aureus infection. Which action by the UAP would require the nurse to intervene?
removes gloves and walks out of the room
Which is the best example of a nurse demonstrating the role of caregiver?
starting an intravenous line in the client's arm
A pulse deficit is the difference between:
the apical pulse and the radial pulse rates.
The nurse is caring for assigned clients who are all stable. Which client should the nurse see first to minimize the spread of infection?
the client who is 48-hours postsurgical procedure
