Nursing Fundamentals

A nurse is caring for a client receiving fluid through a peripheral IV catheter. Which of the following findings at eh IV site should the nurse recognize as infiltration?

Skin blanching

A nurse is planning care a for client who has dysphagia following a stroke. The nurse should initiate a referral for which of the following therapies?

Speech therapy

Which of the following techniques should the nurse use when performing nasotracheal suctioning for a client?

Apply intermittent suction when withdrawing the catheter

A nurse is caring for a postoperative adult who refuses to use an incentive spirometer following major abdominal surgery. Which of the following is the nurse's priority action?

Determine the reasons why the client is refusing to use the incentive spirometer.

A nurse is reviewing a protocol in preparation for suctioning a client who has a new tracheotomy. Which of the following is an appropriate action for the nurse to take?

Select a suction catheter that is half the size of the lumen

A charge nurse is observing a newly hired nurse who prepares a sterile field. Which of the following indicates tot he charge nurse that the sterile filed is contaminated?

Sterile field is opened on a wet surface

A nurse in a long-term care facility notes that a client coughs frequently during meals and suspects dysphagia. The nurse should assess the client for which of the following behavioral signs of dyspahgia?

Storing food in the mouth

A nurse is preparing to insert an IV catheter into a client's arm prior to initiating IV fluid therapy. Which of the following interventions should the nurse implement to prevent infection?

Thread the IV catheter so that the hub rests at the insertion site.

A hospice nurse is providing end of life care to a client who has terminal lung cancer. The client states, " I am so tired ans afraid of not being able to catch my breath." Which of the following is an appropriate response by the nurse?

" I will be able to give you a medication to help your breathing."

A nurse is caring for a client who has an NG tube that is irrigated every 8 hr. Which of the following should be used to irrigate the tube in order to maintain fluid and electrolyte balance?

0.9% sodium chloride

A nurse is preparing to administer ampicillin 40 mg/kg/day PO divided in equal doses every 6 hour to a toddler who weighs 10 kg. Available is ampicillan oral suspension 125mg/5ml. How many mL should the nurse administer per dose. ( Round to the nearest whole number).

4 mL per dose

A nurse is providing teaching about a clear liquid diet. Which of the following should the nurse instruct the client to avoid?

Orange Sherbet

A nurse is caring for a client receiving IV fluids. During a routine check, the nurse determines that the client had developed phlebitis and removes the IV catheter. Which of the following actions should the nurse take next?

Place a warm compress over the IV site

A nurse is caring for a client who is having difficulty voiding following the removal of an indwelling urinary catheter. Which of the following actions should the nurse take?

Pour warm water over the client's perineum

A nurse is caring for a client who has left sided paralysis after a CVA. The client is unable to bear his own weight. Which of the following actions is an appropriate method to move the client from his bed to his wheelchair?

Use a hydraulic lift ans have an AP help move the client

A nurse is evaluating a client with right leg weakness ans is learning to use a rubber-tipped standard walker. Which of the following actions by the client indicate proper use of the walker?

Uses a lifting motion to move the walker

A nurse is reviewing practice guidelines with a group of newly licensed nurses. Which of the following falls within the RN scope of practice?

Initiate an enteral feeding though a PEG tube

A nurse is preparing a change of shift report. Which of the following is an appropriate method to communicate continuity of care?

Situation, Background, Assessment, and Recommendation (SBAR)

A nurse is speaking with the parent of an infant who has a cardiac defect. After the parent expresses concern, which of the following is an appropriate response?

" Tell me about your baby while I bathe her."

A nurse is caring for a client who reports pain. When documenting the quality of the client's pain on an initial pain assessment, the nurse should record which of the following client statements?

" The pain is like a dull ache in my stomach."

A nurse is implementing a plan of care for an older adult client who is at risk for falls. Which of the following is an appropriate nursing action?

Implement a regular toileting schedule

A nurse is caring for a client who has taken in 2,600 ml of fluids in 24 hr. Which of the following is an expected output for the client?

2,500 ml

A nurse is preparing to administer Demerol 80 mg IM from a 100 mg prefilled syringe. After the ingection, which of the following is an appropriate action by the nurse?

Have another nurse witness the disposal of the excess medication.

A nurse is transcribing new orders for insulin based on a clients blood glucose readings. The nurse notes that the provider did not write the frequency for checking blood glucose levels on the order sheet. Which of the following is the appropriate action by the nurse?

all the health care provider to determine the frequency of blood glucose checks

A nurse has accepted a verbal prescription for three tenths of a milligram of Synthroid IV stat for a client who has myxedematous coma. How should the nurse transcribe the dosage of this medication in the client's medical record?

0.3 mg

A nurse is conducting a respiratory assessment for four clients. Which of the following should the nurse recognize as an abnormal respiratory assessment finding?

An adolescent who has visible accessory muscle movement when breathing

A nurse is caring for a client with cancer who lives at home with her spouse. The spouse tells the nurse that the client is in pain "all the time". Which of the following actions is most important for the nurse to take?

Ask the client to rate her pain

A nurse is caring for a client who has a prescription for wound irrigation. Which of the following actions should the nurse take?

Cleanse the would from the center outside

A nurse is providing teaching to a client about techniques to promote sleep. Which of the following instructions should the nurse include in the teaching?

Consume a light snack of carbohydrates at bedtime

A charge nurse is discussing the responsibility of nurses caring for clients who have clostridium difficile. Which of the following information should the nurse include in the teaching?

Have family members wear a gown and gloves when visiting.

A nurse is caring for a client whom a naso-gastric tube is ordered for stomach decompression. Which of the following actions is appropriate when inserting the NG tube?

Have the client take sips of water to promote insertion of the NG tube into the esophagus

A nurse is caring for a client with an order for 5 units of Regular insulin and 10 units of NPH insulin to be mixed together and administered subcutaneously. List the correct order of steps for this procedure.

Inject 10 units of air into the bottle of NPH insulin Inject 5 units of air into the bottle of Regular insulin Withdraw the correct dose of Regular insulin from the bottle Withdraw the correct dose of NPH insulin from the bottle

A nurse is caring for a client following an acute myocardial infarction. The client is concerned that providing self-care will be difficult due to extreme fatigue. Which of the following strategies should the nurse implement to promote the client's independence?

Instruct the client to focus on gradually resuming self-care tasks

Which of the following should indicate to a nurse the need to suction a client's tracheostomy?

Irritability

A nurse is preparing to transfer a client form the bed to the stretcher using a slide board. Which of the following actions should the nurse take?

Lower the head of the bed

A nurse is reinforcing teaching regarding the use of a cane to a client who has left-leg weakness. Which of the following should the nurse include in the teaching?

Maintain 2 points of support on the floor

A nurse is transcribing new prescription orders for a client. Which of the following prescription is accurately transcribed by the nurse?

Morphine sulfate 4 mg IV bolus every 2 hr PRN for incision pain

A nurse is assisting a client with range of motion exercise of the neck,. Which of the following should the nurse suggest to promote neck rotation?

Move her head from side to side

A nurse is planning to delegate client care to an assistive personnel (AP). Which of the following factors is most important for the nurse to consider before delegating care?

The facility's job description for the AP

A nurse in a long term care facility is planning to perform hygiene for a new resident. Which of the following assessment questions is the nurse's priority before beginning this procedure?

" Are you able to help with your hygiene care?"

A nurse is caring for a client who is scheduled to be transferred to a long-term care facility. The client's family questions the nurse about the reasons for the transfer. Which of the following responses made by the nurse is appropriate?

" Have a seat and let me tell you what has happened."

A nurse is providing teaching to a client who is receiving chemotherapy. Which of the following client statements indicates an understanding of the teaching?

" I will disinfect my toothbrush weekly."

A nurse is caring for a client who needs a 24 hr urine collection initiated. Which of the following client statements indicates an understanding of the procedure?

"I flushed what I urinated at 7 a.m. and have saved all urine since."

A nurse is educating a family member of a client who is immobile about how to prevent back injury associated with moving the client up in bed. Which of the following statements by the family should indicate to the nurse that he understands the teaching?

"I will leverage my weight against my wife and shift as I move her."

A nurse on an oncology unit is caring for a client who has tears in his eyes ans states," The doctor just told me that I don't have long to live." Which of the following is an appropriate response by the nurse?

"Tell me more about how you're felling."

A client is receiving continuous tube feeding via NG tube. The client has 3 episodes of vomiting in 12 hr. Which of the following actions should the nurse take?

Aspirate for residual

A nurse is planning care of an adolescent who is postoperative following a lumbar laminectomy. Which of the following interventions should the nurse include in the plan of care?

Allow the adolescent to make decisions regarding his daily routine

A nurse is providing discharge teaching for a client who has a new prescription for a home oxygen concentrator. Which of the following instructions should the nurse give to the client ans his family?

Check the cord routinely for frays or tearing Consider purchasing a generator for power outage Monitor for signs of hypoxia

A nurse is performing a Romberg's test during the physical assessment of a client. Which of the following techniques should the nurse use?

Have the client stand with arms at side and feet together

A nurse is performing assessments of clients of various ages. Which of the following is an appropriate physical assessment technique?

Measurement of an adult's blood pressure with a cuff whose bladder surrounds 80% of the client's arm circumference

A nurse is caring for a client who has tuberculosis. Which of the following actions should the nurse take? Select all that apply

Place the client in a negative pressure room Wear gloves when assisting the client with oral care Use antimicrobial sanitizer for hand hygiene

A nurse is completing and admission assessment of an older adult client. Which of the following findings is a potential indication of abuse?

Presence of bruises on the arms in various stages of healing

A nurse is obtaining a health history from a client who had hearing loss. Which of the following actions by the nurse is appropriate?

Rephrase rather than repeat misunderstood information

A nurse is caring for a client in the immediate postoperative period. The nurse should recognize that which of the following positions maximizes the effectiveness of incentive spirometry?

Semi-Fowler's

A nurse is reviewing the medical records for a client who has a pressure ulcer. which of the following is an expected finding?

Serum albumin level of 3g/dL

A nurse is caring for a client who has dementia. Which of the following interventions should the nurse take to minimize the risk for injury to this client?

Use a bed exit system alarm

Which of the following precautions is important to take when a nurse is caring for a client who has diarrhea sue to Shigella?

Wash hands before and after client contact

A nurse is caring for a client who is refusing a scheduled blood transfusion for religious reasons. The client's partner wants the client to have the blood transfusion. Which of the following actions should the nurse take?

Withhold the scheduled blood transfusion