PN Fundamentals Online Practice 2023 A

A nurse is caring for a client who has COPD. Select the 3 findings that require follow-up.

-Breath sounds -Oxygen saturation -Temperature

A nurse is caring for a client who is postoperative following abdominal surgery. Click to highlight the findings the nurse should report to the provider.

-Urinary output -Reported pain level -Vital signs

A nurse is preparing to administer a topical medication to a client. Which of the following actions should the nurse take?

Compare the label of the medication container with the medication administration record three times.

A nurse is collecting data from a client following a lumbar puncture. The nurse should identify which of the following findings as a potential adverse effect of this procedure?

Headache

A nurse is calculating the intake and output for a client over the last 8 hr. The client is receiving a continuous IV infusion at 150 mL/hr and had 4 oz of juice and 0.5 L of water. How many mL of fluid should the nurse document as the client's intake for the last 8 hr? (Round your answer to the nearest whole number.)

1,820 mL

A nurse is reinforcing teaching with a new parent or guardian who is concerned about sudden unexpected infant death (SUID). Which of the following statements by the client indicates an understanding of the teaching?

"I will remove all stuffed animals from my baby's crib."

A nurse is caring for a client who is scheduled for surgery the following day. During the night, the client is unable to sleep and is restless. Which of the following statements should the nurse make?

"It must be difficult facing this type of surgery."

A nurse is reinforcing teaching about advance directives with a client who has end-stage renal disease. Which of the following client statements indicates an understanding of the teaching?

"I know that I can change my advance directives if I need to in the future."

A nurse in a provider's clinic is caring for a client who has heart failure. The nurse is evaluating the client's understanding of the teaching. Select the 3 client statements that indicate an understanding of the teaching.

"I know to call my doctor if I gain 3 pounds or more in 2 days" "I am eating fewer potato chips and more fruit for snacks" "I am limiting my sodium intake to 2 grams daily"

A nurse is reinforcing teaching with a client who has hypertension and a prescription to measure their blood pressure daily. Which of the following client statements indicates an understanding of the teaching?

"I should remove constrictive clothing prior to measuring my blood pressure."

A nurse is reinforcing teaching with a client who is scheduled for a bladder scan. Which of the following instructions should the nurse include in the teaching?

"I will place a gel pad directly above your pubic area before I place the probe."

A nurse is preparing to remove a client's peripheral IV catheter. After performing hand hygiene and applying clean gloves, which of the following actions should the nurse take first?

Clamp the infusion tubing.

A nurse is reinforcing teaching with the caregiver of a client who is near death. Which of the following instructions should the nurse provide?

"Provide mouth care to them at least every 2 hours."

A nurse is preparing a client for a Romberg test. Which of the following statements should the nurse make?

"Stand with your feet together and your arms at your sides."

A nurse is caring for a client who has metastatic cancer and practices Catholicism. The client asks the nurse to discuss the afterlife with them. Which of the following statements by the nurse assists in meeting the client's spiritual needs?

"Tell me what the afterlife means to you."

A nurse is reinforcing teaching about hospice care measures with the family of a client who is dying. Which of the following statements by a member of the client's family indicates an understanding of the teaching?

"We will keep their room cool to help them breathe better."

A nurse is caring for a client who has recently undergone a total bilateral mastectomy. Which of the following statements by the client requires immediate action by the nurse?

"When I look at myself in the mirror, I don't know if I can go on."

A nurse is reinforcing teaching with a client about self-administration of ophthalmic drops. Which of the following instructions should the nurse include?

"You should cleanse your eye from the inner to the outer edge prior to putting in the drops."

A nurse is assisting with the care of a recently deceased client. Which of the following actions should the nurse complete prior to the family viewing the body?

Clean soiled areas of the body.

A nurse is reinforcing teaching with a client who has pneumonia and a productive cough. Which of the following instructions should the nurse include in the teaching?

"You should cover your mouth with a tissue when you cough."

A nurse is caring for a client in a medical-surgical unit. After reviewing the findings, which of the following actions should the nurse plan to take? Select the 3 actions that the nurse should plan to take.

-Administer analgesic prior to planned activities -Assist the client to dangle their legs at the bedside prior to standing -Delegate the application of sequential compression devices to assistive personnel

Assisting With the Care of a Client Who Reports an Extended Period of Constipation. Based on the client's clinical findings, which of the following actions should the nurse take?

-Assist the client to a left side-lying position with the right knee flexed -Administer a cleansing enema -Auscultate the client's bowel sounds -Perform a manual digital examination of the client's rectum

A nurse is assisting with caring for a female client who has a newly placed ileostomy. Complete the following sentence by using the lists of options. The nurse should first address the___________ followed by the ______________

-Color of the stoma -Skin condition around the stoma

A nurse is planning care for a client who is disoriented and at risk for falls. Which of the following interventions should the nurse include? (Select all that apply.)

-Ensure that the client is wearing nonskid slippers. -Place the client in a room near the nurses' station. -Reinforce teaching about how to use the call bell.

A nurse is caring for a client who had a spinal cord injury and has paraplegia. Click to highlight the findings below that that require intervention by the nurse.

-Passive range-of-motion exercises to lower extremities performed once daily -Plantar flexion contractures noted bilaterally -Left heel has 1.3 cm x 1.3 cm (0.5 in x 0.5 in) area of Non blanchable erythema; skin is intact

A nurse is assisting with admitting a client to a health care facility. A nurse is assisting in the care of a client who is being placed on transmission-based precautions. Which of the following actions should the nurse plan to take when caring for this client? Select all that apply.

-Wear an N95 mask when caring for the client -Place a trash can for soiled linens inside the client's room -Place the client in a negative airflow room -Perform hand hygiene before leaving the client's room

A nurse is assisting in the care of a client. When prioritizing care for the client, the nurse should first

-first, plan a turning and positioning schedule -second, apply a hydrocolloid dressing to the client's sacrum -third, request a prescription for a pressure redistribution bed

A nurse is providing oral hygiene for a client who is unconscious. Identify the sequence of the steps the nurse should take. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)

1. Assess the client's gag reflex is the first step. 2. Position the client on their side with their head turned to the side is the second step. 3. Place a towel under the client's head with an emesis basin under their chin is the third step. 4. Separate the client's upper and lower teeth with an oral airway device is the fourth step. 5. Cleanse the client's mouth using a toothbrush is the fifth step

A nurse is caring for four clients. For which of the following clients should the nurse use the therapeutic communication technique of silence?

A client who has just experienced the death of their child

A nurse is preparing to perform a wound irrigation for a client who has a stage 3 pressure injury. Which of the following supplies should the nurse plan to use?

A piston syringe

A nurse is providing wound care for a group of clients. Which of the following wounds should the nurse identify as healing by secondary intention?

A stage 3 pressure injury on the coccyx

A nurse is assisting with the plan of care for a client who has a bacterial infection and a persistent oral temperature of 38.9° C (102° F). Which of the following interventions should the nurse include in the plan of care to treat the fever?

Administer acetaminophen.

A nurse is assisting in the care of four clients who are required to provide informed consent for treatment. The nurse should identify that which of the following clients is able to provide informed consent?

An 18-year-old client who has acute appendicitis

A nurse is reinforcing teaching about carbohydrate counting with a client who has a new diagnosis of diabetes mellitus. Which of the following actions should the nurse take first?

Ask the client what they already know about meal planning.

A nurse is assisting with the admission of a client who has active tuberculosis. Which of the following actions should the nurse plan to take?

Assign the client to a negative pressure airflow room

A nurse is caring for a client who has a new prescription for oxygen at 7 L/min via simple face mask. Which of the following actions should the nurse take to ensure client safety?

Attach a humidifier to the base of the flow meter.

A nurse is using Maslow's hierarchy of needs in assisting with discharge planning for a client. Which of the following activities should the nurse recommend as the priority for this client?

Attend an exercise program.

A nurse is explaining ethics and values to a newly licensed nurse. The nurse should explain that allowing a client to make a decision about a treatment is an example of which of the following ethical principles?

Autonomy

A nurse is caring for a client who reports itching 30 min after receiving a newly prescribed medication. Which of the following data should the nurse document in the client's medical record?

Client states, "I started to itch after taking that medication."

A nurse is preparing to care for a client that identifies with a particular ethnic group the nurse has never worked with before. Which of the following actions is the priority for the nurse to deliver culturally appropriate care?

Determine how their own cultural beliefs could impact care delivery.

A nurse is caring for a client who is refusing medical treatment. Which of the following actions should the nurse take?

Document the client's refusal of the treatment.

A nurse is caring for a client who has an indwelling urinary catheter. Which of the following actions should the nurse take to prevent urinary tract infections?

Drain urine from the tubing before ambulation.

A nurse is reinforcing teaching with a client who has a partial hearing loss about how to modify the home environment. Which of the following is a priority modification that the nurse should include?

Flashing smoke alarm

A nurse is caring for a client who has dysphagia following a stroke. Which of the following interventions should the nurse use when feeding the client?

Instruct the client to tilt their head forward while eating.

A client who has advanced cancer tells the nurse that they have a difficult time talking to anyone about the illness. Which of the following actions should the nurse take to encourage therapeutic communication?

Let the client know that, as their nurse, they are available and willing to listen

An assistive personnel (AP) asks a nurse for information about the Health Insurance Portability and Accountability Act (HIPAA). Which of the following information should the nurse give the AP about the purpose of HIPAA? (Select all that apply.)

Mandates protection of the client's confidential health care information

A nurse is caring for a client who is receiving intermittent enteral feedings. Which of the following is the first action the nurse should take?

Measure the client's gastric residual before each feeding.

A nurse is preparing to administer oxygen to a client who has heart failure and is having severe difficulty breathing. Which of the following oxygen delivery equipment should the nurse select to provide the highest concentration of oxygen to the client?

Nonrebreather mask

A nurse is caring for a client who has dyspnea caused by a respiratory infection. The nurse should assist the client into which of the following positions?

Orthopneic

A nurse is moving a client up in bed with the assistance of a second nurse. Which of the following actions should the nurse take?

Place feet apart with the foot nearest the head of the client's bed in front of the other foot.

A charge nurse is reinforcing teaching with an assistive personnel (AP) about performing pulse oximetry. Which of the following information should the nurse include in the teaching?

Remove polish from the client's fingernail before applying the oximetry probe.

A nurse is planning to administer medication to a client who has a Clostridium difficile infection. Which of the following actions should the nurse plan to take to prevent the transmission of this infection to others?

Remove the cover gown in the client's room after providing care.

A nurse is preparing to remove staples from a client's incision. Which of the following actions should the nurse take?

Remove the staple from the skin after both sides are visible.

A nurse and an assistive personnel (AP) are providing postmortem care for a deceased client prior to visitation by the family. Which of the following actions by the AP requires intervention by the nurse?

Removing the client's dentures

A nurse is preparing to transfer a client from an acute care facility to a long-term care facility. Which of the following information should the nurse plan to include in the transfer report?

Resolved health conditions.

A nurse in a provider's office is providing care for a client who has minimal exposure to sunlight. Which of the following interventions should the nurse recommend?

Take vitamin D supplements.

A nurse is collecting data from an older adult client. Which of the following findings should the nurse report to the provider?

The client reports urinary incontinence.

A nurse is evaluating the crutch-walking technique of a client who is required to keep weight off their right leg. Which of the following is the proper crutch gait for this client?

Three-point

A nurse is collecting data on four clients. Which of the following findings should the nurse report to the provider?

Urine output of 200 mL over 8 hr

A nurse is reinforcing teaching with a client who speaks a different language than the nurse. Which of the following actions should the nurse take?

Use printed materials written in the client's language.