Nursing Fundamentals Review

A nurse is caring for a middle adult client. Which of the following statements indicated that the client has completed Erikson's development task for her age group?

" I think I have done a good job with my children since they are all independent now"

A nurse is preparing to insert an indwelling urinary catheter. Which of the following instructions should the nurse give the client to ease the passage of the catheter through the urinary meatus?

"Bear Down"

A charge nurse is providing teaching to a newly licensed nurse about removing sutures from a clients laceration. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

"I will clip each suture close to the skin and pull it through from the other side?

A nurse is measuring the blood pressure of several client. Which of the following results is within the expected reference range for blood pressure?

116/70 mmHg

A nurse is reinforcing teaching with the parent of a child who is to take 30 mL of a liquid medication. The parent has a hollow medication spoon that has marks to indicate teaspoons and tablespoons. How many tablespoons of medication should the nurse instruct the parent to give the child?

2 TBS

A nurse is caring for a client whose intake and output flow sheet for 0700 to 1500 indicates the following: voided x3: 350 mL, 200 mL, 150 mL: wound drainage 2 tsp; and emesis 2 oz. What is the total ouput in milliliters the nurse should document for this 8 hr period

770 mL

A nurse is collecting data from a client who is undergoing a physical examination. Following inspection, which of the following techniques should the nurse use next when evaluating the client abdomen?

Auscultation

A nurse in a providers office is collecting data from a 3 yr old client during a routine physical examination. Which of the following findings should the nurse report to the provider?

Cannot walk up stairs independently

A nurse discovers that a client received the wrong medication Which of the following actions should the nurse take first?

Collect data from the client

During a physical examination of a client, the nurse suspects strabismus. Which of the following tests should the nurse use to collect additional data?

Corneal light reflex

A nurse on a medical-surgical unit is admitting a client. Which of the following pieces of information should the nurse document in the client's record first?

Data collection for the client

A nurse is caring for a client who has terminal pancreatic cancer. When the client states, "Its devastating that I will not be here to see my child graduate", the nurse should identify that the client is in which of the following stages of grief as defined by Kubler-Ross

Depression

A nurse is caring for an older adult client who has an in-the-canal hearing aid. The client states that the hearing aid is making whistling sound. The nurse should identify which of the following factors as the source of this sound?

Excessive wax in the ear canal

A nurse is reinforcing teaching with a middle adult client about disease prevention and health maintenance. Which of the following diagnostic tests should the nurse recommend as part of routine health screening for women 50 to 64 years of age?

Eye examination every 2 years

A nurse is instilling antibiotic ear drops for a client who has an ear infection. Which of the following actions should the nurse take?

Have the client lie on the side opposite the infected ear

A nurse is collecting data from a client who is experiencing stress and anxiety regarding a recent diagnosis. Which of the following findings should the nurse expect?

Increased blood pressure

A client who has glaucoma of the right eye self-administers timolol eye drops by looking at the ceiling, instilling a drop onto the center of the conjunctival sac, and applying gentle pressure to the lower lid with a facial tissue. After observing this process, Which of the following actions should the nurse take?

Instruct the client to apply pressure to the inside corner of the eye after

A nurse in the emergency department is caring for an inmate who has a laceration and is bleeding. The client was brought to the facility by a guard who asks the nurse about the clients HIV infection status. Which of the following action should the nurse take?

Instruct the guard to ask the inmate

A charge nurse is observing a newly licensed nurse requires interventions?

Obtaining cotton balls for the tracheostomy care

A nurse is preparing to administer a bolus feeding to a client through an NG tube and observes that the exit mark on the tube has moved since the last feeding. Which of the following actions should the nurse plan to take?

Request an X-ray of the client abdomen

A nurse is preparing to administer a unit of packed RBCs to a client when she discovers that the IV line is no longer patent. The IV team can send someone in 30 minutes to initiate a new line. Which of the following actions should the nurse take?

Return the blood to the laboratory

A nurse is preparing to administer a medication to a client. Which of the following administration schedules indicates that the nurse should administer the medication once and as soon as a possible?

STAT prescription

A nurse is reinforcing teaching with a client about a surgical procedure that she will undergo later in the day. The client states that no one has spoken to her about this procedure before. Which of the following actions should the nurse take

Stop reinforcing the teaching and check with the surgeon about informed consent

A nurse is caring for an adult client who is grieving following the death of a loved one. Which of the factors places the client at risk of developing complicated grief?

The death was sudden

A nurse is reinforcing teaching about bladder retraining for a client who has urinary incontinence. Which of the following instructions should the nurse include?

Try to block the urge to urinate until the next scheduled time

A nurse is collecting data about a clients respiratory system. Which of the following breath sounds should the nurse expect to hear over the periphery of the major lung fields?

Vesicular

A nurse is reviewing the laboratory results of a client who is preoperative. Which of the following results should the nurse report to the surgeon?

WBC count 18,000/mm^3

A nurse is reinforcing teaching with a client about how to remove a soiled dressing. Which of the following statements by the client indicates an understanding of the teaching?

"I'll wear nonsterile gloves"

A nurse is preparing to change a dressing on a client who is receiving negative-pressure wound therapy (NPWT). In what sequence should the nurse plan to take the following action?

1) Turn off the vacuum on the NPWT device and administer the prescribed analgesic. 2) Remove the soiled dressing and preform hand hygiene. 3) Apply sterile or clean gloves and irrigate the wound. 4) apply skin protectant or a barrier film to the skin sound the wound 5) place prepared foam into the wound bed and cover with transparent fill and turn on NPWT unit 6) Connect the tubing to the transparent film and turn on the NPWT unit

A nurse is caring for a client who has a hearing impairment. Which of the following interventions should the nurse use when speaking with the client

Face the client when speaking

A nurse is collecting data from a client who is having difficulty breathing. The nurse should assist the client into which of the following positions?

Fowlers

A nurse is leading an education session about disposing of biohazardous materials. Which of the following instructions should the nurse include in the teaching?

Place soiled linen in a single linen bag

A nurse is preparing to administer a tap water enema to a client. Which of the following actions should the nurse take?

Place the client in a left Sims' position