Pre-Assessment Quiz Fundamental 2023

A nurse is reinforcing teaching about car seat safety with a parent of an infant who weighs 4.5 kg (10lb). Which of the following actions by the parent indicates an understanding of the teaching?

Place a small towel to the side of the infant's head to minimize head movement Rationale: The parent should minimize the infant's head movements by rolling a small towel or blanket and placing it to the side of the infant's head.

A nurse is reinforcing discharge teaching with a client who had a total hip arthroplasty. Which of the following information should the nurse include in the teaching?

Sit with legs apart at the ankles rationale: the nurse should instruct the client to not cross legs beyond the midline of the body; therefore, the client should sit with legs apart

A charge nurse observes a nurse administer intermittent tube feedings via an NG tube to a client. Which of the following actions should prompt the charge nurse to intervene?

The nurse allows the client to rest in a supine position during feeding Rationale: The nurse should position the head of the bed at a minimum of 30⁰ of elevation to prevent aspiration from reflux during feedings.

A nurse is preparing an in-service presentation for a group of newly licensed nurses about the use of restraints. Which of the following should the nurse include in the criteria for applying restraints?

The nurse has already considered alternatives to restraint Rationale: Restraints physically prevent a client from moving freely in the environment. However, they are a last resort. The nurse must consider other alternatives before implementing a restraint device.

A nurse in a long-term care facility is planning care for several clients. Which of the following activities should the nurse plan to delegate to an assistive personnel (AP)

Assisting a client with feeding

A nurse is reinforcing teaching with a client who has left hemiparesis about how to use a cane. Which of the following instructions should the nurse include?

Hold the cane on the right side to provide support for the weaker leg Rationale: The client should hold the cane with her stronger hand, in this case the right hand.

A nurse is administering a cleansing enema for a client who has constipation, Which of the following actions should the nurse take?

Hold. the container of solution 30 cm (12in)above the anus Rationale: Holding the container of solution 30 to 49 com (12 to 18 in) above the anus generates enough force for the fluid to reach far enough into the colon to cleanse it well

A nurse is collecting data from an older adult client who has had some bone density loss. The nurse observes excessive forward curvature of the thoracic spine. The nurse should document this finding using which of the following terminology?

Kyphosis Rationale: Kyphosis, a forward "hunchback" of the thoracic spine, usually a result of osteoporosis. It is most common in older adults and tends to increase with aging

A nurse is preparing to administer an IM injection to a client using a medication from an ampule. Which of the following actions should the nurse plan to take?

Withdraw medication from the center of the ampule Rationale: The nurse should insert the needle into the center of the ampule without touching the rim with the needle tip or shaft. This ensures the needle remains sterile.

A nurse is caring for a client who wants information about a complementary or alternative healing modality to help her reduce stress. The nurse should suggest which of the following modalities in which the client can practice poses and meditation to achieve wellness?

Yoga Rationale: Yoga is a mind-body therapy that helps clients focus on creating an inner balance to promote healing. Clients can practice yoga with different body poses and meditations. Practicing yoga can loosen stiff joints, stimulate circulation, manage stress, and enhance overall wellbeing

A nurse is preparing to administer a subcutaneous injection to a client. Which of the following actions should the nurse plan to take?

Cleanse the injection site with a circular motion Rationale: The nurse should cleanse the injection site with a circular motion starting at the center and cleaning in widening circle to approximately 5cm (2in) in diameter to remove skin secretions, which can contain microorganisms

A nurse is assisting with speaking in front of a group of nurses about new guidelines to prevent pressure ulcers. Which of the following actions by the nurse demonstrates confidence?

The nurse stands tall before talking Rationale: The nurse should stand tall and erect to exhibit confidence

A nurse is assisting with the admission of a client who is about to have elective surgery. The client tell the nurse she feels anxious. Which of the following responses should the nurse make?

"Tell me about your concerns" Rationale: This response is an example of the therapeutic communication technique of providing general leads. It encourages the client to express his feelings and gives the nurse additional data about the client

A nurse is calculating the total fluid intake for a client during a 4-hr period. The client consumed 1 cup of coffee, 4 oz of orange juice, 3 oz of water, 1 cup of flavored gelatin, 1 cup of tea, 5 oz of broth, and 3 oz of water. The nurse should record how many mL of intake on the client's record?

1170 Rationale: Step 1: What is the unit of measurement to calculate? mL Step 2: Set up the equation and solve for X. 1 cup = 8 oz 1 oz/30 mL = 8 oz/X mL X = 240 mL Step 3: Reassess to determine whether the fluid volume makes sense. If 1 oz = 30 mL, it makes sense that 8 oz (1 cup) = 240 mL. Step 1: What is the unit of measurement to calculate? mL Step 2: Set up the equation and solve for X. 1 oz/30 mL = 4 oz/X mL X = 120 mL Step 3: Reassess to determine whether the fluid volume makes sense. If 1 oz = 30 mL, it makes sense that 4 oz = 120 mL. Step 1: What is the unit of measurement to calculate? mL Step 2: Set up the equation and solve for X. 1 oz/30 mL = 3 oz/X mL X = 90 mL Step 3: Reassess to determine whether the fluid volume makes sense. If 1 oz = 30 mL, it makes sense that 3 oz = 90 mL. Step 1: What is the unit of measurement to calculate? mL Step 2: Set up the equation and solve for X. 1 oz/30 mL = 5 oz/X mL X = 150 mL Step 3: Reassess to determine whether the fluid volume makes sense. If 1 oz = 30 mL, it makes sense that 5 oz = 150 mL. After converting all fluid amounts to mL, add them to calculate the client's total fluid intake. 240 + 120 + 90 + 240 + 240 + 150 + 90 = 1170 mL

A nurse is assisting a client with range-of-motion exercises of the hands and wrists. Which of the following terms should the nurse use when documenting the client bringing her fingers together, closing the spaces between them?

Adduction Rationale:Adduction is movement of an extremity toward the body's midline or a limb's midline. Adduction of the fingers would be to bring the fingers of the hand together

A nurse is caring for an older adult client who reports occasional constipation. The nurse should inform the client that straining while defecating can cause which of the following?

Dysrhythmias Rationale:When the client exerts pressure to expel feces, he uses the Valsalva maneuver, with which he contracts his abdominal muscles voluntarily and exhales against a closed airway while bearing down. When he exhales and releases the sudden pressure, dysrhythmias can occur.

A nurse is reinforcing teaching with a client who has trouble sleeping at night. Which of the following beverages should the nurse recommend the client to drink to avoid caffeine consumption?

Lemon-lime soda Rationale: The nurse should recommend lemon lime soda because it does not contain caffeine, which acts as a stimulant

A nurse is caring for a client who is in contact isolation. When exiting the client's room in what order should the nurse take the following steps when removing her personal protective equipment?

Removes gloves, Remove protective eyewear, remove gown, remove mask, perform hand hygiene Rationale:First, the nurse should remove her gloves. Remove gloves by grasping cuff and pulling glove inside-out over hand. This will prevent contamination of the skin. The nurse should discard this glove. With ungloved hand, tuck finger inside the cuff of the remaining glove, then pull it off and inside-out. Next, the nurse should remove her protective eyewear. In order to prevent transmission of the contaminant, eyewear should not be removed with contaminated gloves. Next, the nurse should remove the gown once the gloves and eyewear are removed. The nurse should touch only the inside of the gown in order to prevent contamination. Untie the gown's waist and neck strings and then allow the gown to fall from the shoulders. The nurse should remove her hands from the sleeves without touching the outside of gown. The gown should be held inside at shoulder seams, and folded inside-out. The gown should be discarded in laundry bag if fabric and discard in the trash can if disposable. The nurse should remove the mask after the gloves, eyewear, and gown have been removed. If the mask loops over the ears, remove it from the ears and pull away from the face. For a tie-on mask, untie the top strings, pull the mask away from the face, and drop it into the trash receptacle. The nurse should not touch the outer surface of the mask. Lastly, the nurse should perform hand hygiene. The nurse should complete hand hygiene prior to leaving the room. Regardless of the type of precautions, the nurse should use thorough hand hygiene before entering and leaving a client's room.

A nurse is assisting with the preparation of an instructional plan for a client who has vision loss. Which of the following strategies should the. nurse include in the plan?

Use of auditory or tactile materials Rationale: The use of auditory or tactile materials bypasses the need to see or read. Therefore, it is an appropriate intervention for clients who have vision loss.

A nurse is collecting data about a client's cardiac functioning. The nurse auscultates an S3 sound. Which of the following causes should the nurse suspect?

Ventricular gallop Rationale: An S3 sound represents a ventricular gallop. Possible causes are hypertension and heart failure