RN Fundamentals Online Practice 2023 B
A nurse is providing teaching to a client who is on protective isolation precautions. which of the following client statements indicates an understanding of the teaching?
"I will wear a face mask when leaving my hospital room." The client is encouraged to wear a face mask because of increased risk for exposure to micro-organisms.
A nurse is preparing a heparin infusion for a client who was admitted to the facility with deep vein thrombosis. the prescription reads 25,000 units of heparin in 0.9% sodium chloride 250 ml to infuse at 800 units/ hr. at what rate should the nurse set the infusion pump? ( round the answer to the nearest whole number. use a leading zero if it applies. Do not use a trailing zero.)
8 ml/hr
A nurse is caring for a client who is receiving a unit of packed RBCs. Exhibit 1 Vital Signs 0800: BP 112/64 mm HgHeart rate 80/minRespiratory rate 18/minTemperature 37.1° C (98.8° F)Oxygen saturation 97% on room air0815: BP 106/54 mm HgHeart rate 100/minRespiratory rate 22/minTemperature 37° C (98.6° F)Oxygen saturation 95% on room air Exhibit 2 Nurses' Notes 0800: Packed RBCs initiated by the charge nurse through an 18-gauge peripheral IV to infuse over 2 hr.0815: Client reports itching and anxiety. Client's face is flushed and has hives.
Allergic reaction is correct. The nurse should identify the client has manifestations of an allergic reaction as evidenced by itching, flushing of the face, anxiety, and urticaria. The nurse should stop the transfusion and notify the provider. Itching is correct. The nurse should identify that itching, flushing of the face, anxiety, and urticaria are manifestations of an allergic reaction to the blood transfusion. The nurse should stop the transfusion and notify the provider.
A nurse in the emergency department (ED) is caring for a client who reports abdominal pain. Exhibit 1 Nurses' Notes 1200: Client arrives to ED and reports abdominal pain and no bowel movement for the past 7 days. Client is undergoing chemotherapy for pancreatic cancer and has been taking 40 mg oxycodone extended-release tablets daily for the past 3 months. Client states they have attempted to relieve constipation for the last 7 days with bisacodyl suppositories and magnesium citrate oral suspension. Client reports that neither therapy initiated defecation.1230: Client transported for abdominal x-ray.1245: Client returned from x-ray. Provider prescribes a hypertonic cleansing enema.1300: Procedure explained to client who verbalized understanding. Exhibit 2 Diagnostic Results 1245: Abdominal x-ray indicates a large amount of fecal material throughout the colon. No evidence of gastrointestinal obstruction observed.
Assist the client to a left side-lying position with the right knee flexed is correct. The nurse should place the client in a left side-lying position with the right knee flexed prior to administering an enema. Because the provider prescribed a cleansing enema for the client, the nurse should prepare the client for the procedure. Administer a cleansing enema is correct. The nurse should administer a cleansing enema for the client as a result of the provider's prescription. A cleansing enema is intended to assist with bowel elimination and remove any impacted fecal matter indicated by the abdominal x-ray. Auscultate the client's bowel sounds is correct. The nurse should auscultate the client's bowel sounds to determine the status of the client's peristalsis. This is a necessary part of determining the presence of bowel sounds, which are an indication of the status of the client's gastrointestinal tract. Perform a manual digital examination of the client's rectum is correct. The nurse should perform a manual digital examination of the client's rectum to determine if impacted stool is present. This is a part of the necessary evaluation of the status of the client's gastrointestinal tract.
A nurse is caring for a female client. Exhibit 1 Medical History Client is receiving chemotherapy for treatment of breast cancer. Exhibit 2 Diagnostic Results Week 1: Hct 42% (37% to 47%)Hgb 15 g/dL (12 to 16 g/dL)WBC count 8,000/mm3 (5,000 to 10,000/mm3)Platelet count 350,000/mm3 (150,000 to 400,000/mm3)Potassium 3.7 mEq/L (3.5 to 5 mEq/L)Week 2: Hct 37% (37% to 47%)Hgb 12 g/dL (12 to 16 g/dL)WBC count 6,000/mm3 (5,000 to 10,000/mm3)Platelet count 100,000/mm3 (150,000 to 400,000/mm3)Potassium 3.6 mEq/L (3.5 to 5 mEq/L)
Bleeding is correct. The client's platelet count is less than the expected reference range. Therefore, the client is at risk for bleeding. Platelet count is correct. The client's platelet count is less than the expected reference range. Therefore, the client is at risk for bleeding.
A nurse is caring for a client who has COPD. Exhibit 1 Nurses' Notes 1000: Client admitted with a productive cough with thick yellow sputum. Breath sounds with crackles heard in left upper lobe and decreased breath sounds at bases bilaterally. Exhibit 2 Vital Signs 1000: Temperature 38.6° C (101.5° F)BP 114/56 mm HgHeart rate 99/minRespiratory rate 32/minOxygen saturation 85% on room air Exhibit 3 Diagnostic Results 1200: Chest x-ray shows lung hyperinflation and left upper lobe pneumonia.
Breath sounds is correct. Crackles are caused by mucous in the airways and are a manifestation of pneumonia. Decreased breath sounds indicate decreased ventilation and require follow-up by the nurse. Oxygen saturation is correct. The client's oxygen saturation is below the expected reference range of 95% to 100%, indicating hypoxia, and requires follow-up by the nurse. Temperature is correct. The client's temperature is greater than the expected reference range, indicating an infection, and requires follow-up by the nurse.
A nurse in a medical-surgical unit is caring for six clients. Exhibit 1 Nurses' Notes 0800: Client 1: Client is admitted with a new diagnosis of rheumatoid arthritis.Client 2: Client has a history of hyperlipidemia. Atorvastatin 20 mg PO administered as prescribed.Client 3: Client is 1 day postoperative. Reports pain as 8 on a scale of 0 to 10. Morphine 5 mg subcutaneous administered as prescribed.Client 4: Client is admitted with a new diagnosis of heart failure.Client 5: Client has a stage 2 pressure injury on the left heel.Client 6: Client is admitted with a new diagnosis of diabetes mellitus. Exhibit 2 Diagnostic Results 0900: Client 1: C-reactive protein 3.2 mg/dL (less than 1 mg/dL)Client 2: Cholesterol 250 mg/dL (less than 200 mg/dL)Client 3: Oxygen saturation 88% (95% to 100%)Client 4: Potassium 3.2 mEq/L (3.5 to 5 mEq/L)Client 5: Prealbumin 14 mg/dL (15 to 36 mg/dL)Client 6: Glycosylated hemoglobin 8%
Client 3 is correct. When using the airway, breathing, circulation approach to client care, the nurse should determine that this client is the priority client to assess. The client has an oxygen saturation that is less than the expected reference range, which is an indication of hypoxia. Client 4 is correct. When using the airway, breathing, circulation approach to client care, the nurse should determine that this client is the next priority client to assess. The client has a potassium level that is less than the expected reference range, which places the client at risk for dysrhythmias.
A nurse is planning teaching for a client who has new diagnosis of type 1 diabetes mellitus about insulin self-admnistration. which of the following actions should the nurse take first?
Determine the client's learning style. using the nursing process, the first action the nurse should take is to assess the client's learning style.
A nurse is caring for a client who has recently started using a behind-the-ear hearing aid. which of the following statements should the nurse identify as an indication that the client understands the use of this assistive device?
I will be sure to remove my hearing aid before taking a shower clients should remove any hearing devices before showering because exposure to water can damage them.
A nurse is reviewing a client's medication prescription that reads, " digoxin 0.25 by mouth every day" which of the following components of the prescription should the nurse verify with the provider?
Medication dose In the prescription, the medication dose is not complete. The number 0.25 should be followed by a unit of measurement, such as mg, to clarify the amount the nurse should administer.
A nurse is caring for a client who has a peripheral IV inserted for fluid replacement. Exhibit 1 Nurses' Notes Day 1: Lactated Ringer's at 100 mL/hr infusing into a 20-gauge IV catheter in left hand. IV dressing dry and intact. IV site without redness or swelling. IV fluid infusing well.Day 2: IV site edematous. Skin surrounding catheter site taut, blanched, and cool to touch. IV fluid not infusing.
Stop the IV infusion is correct. The client has manifestations of IV infiltration. The nurse should stop the IV infusion and remove the IV catheter to reduce the risk for tissue damage. Elevate the client's left arm is correct. The nurse should elevate the client's left hand to decrease swelling and reduce the risk for tissue damage. Apply heat to the client's left hand is correct. The nurse should apply heat to the client's left hand to reduce swelling and promote comfort.
A charge nurse is observing a newly licensed nurse prepare a sterile field for a dressing change. which of the following actons by the newly licensed nurse required intervention by the charge nurse?
The newly licensed nurse places the cap of a bottle of sterile saline solution on the sterile field. The newly licensed nurse should place the cap with the sterile side up on a clean surface because the outer edges are unsterile and will contaminate the sterile field.
A nurse is admitting a client to a health care facility. Exhibit 1 Nurses' Notes 1100: Client reports fever, chills, cough, and night sweats for past 2 weeks. Client has recently traveled outside of the country. Lethargic, but oriented to person, place, and time. Crackles heard in lower lobes of lungs upon auscultation. Cough is productive with small amounts of blood. Reports tightness in chest and pain when coughing. Reports losing 5 lb in the last week. Has no appetite and is nauseated. Obtained blood work, chest x-ray, and sputum culture as prescribed. Exhibit 2 Vital Signs 1100: BP 138/72 mm HgHeart rate 80/minRespirations 22/minTemperature 38.3° C (101.1° F)Oxygen saturation 90% on room air Exhibit 3 Diagnostic Results 1400: Chest x-ray positive for inflammation and infiltrates in upper lobesQuantiFERON-TB positive (negative)Tuberculosis culture positive (negative)
Wear an N95 mask when caring for the client is correct. The nurse should identify the client has tuberculosis, which requires airborne isolation. Therefore, the nurse should wear an N95 mask when caring for the client. Place a container for soiled linens inside the client's room is correct. The nurse should identify the client has tuberculosis, which requires airborne isolation. Therefore, the nurse should place a container for soiled linens inside the client's room to prevent transmission of the infection. Place the client in a negative airflow room is correct. The nurse should identify the client who has tuberculosis should be placed in a negative airflow pressure room that provides at least 6 to 12 air exchanges per hour through a HEPA filtration system. Remove mask after exiting the client's room is correct. The nurse should remove their mask after leaving the room of a client who is in airborne precautions for tuberculosis to prevent exposure to the infection.
A nurse is caring for a client in a medical-surgical unit. Exhibit 1 History and Physical 3 days ago: Current diagnoses: type 2 diabetes mellitus Past medical history: left below-the-knee amputation 5 years ago. Exhibit 2 Nurses' Notes 3 days ago, 1000: Client admitted from home reports a pressure injury. Provider and wound care nurse at bedside. Slough and eschar covering pressure injury on sacrum. Debridement performed. Malodorous. Pressure injury stage 4 with two tunnels present. Pressure injury is 10 cm (4 in) in diameter and 3 cm (1.2 in) at the deepest point. Tunneling locations at one and eight o'clock and measure at 6 cm (2.4 in) and 4 cm. (1.6 in) respectively. Wound care nurse initiated negative pressure wound therapy.Today, 0800: Client sitting in bed, alert and oriented x4. Client states, "I can't wait to get this thing off of me." States pain is a 5 on a scale of 0 to 10. PRN analgesic prescribed.0830
When evaluating outcomes, the nurse should identify that the assessment findings of granulation tissue covering the wound bed, no odor present, increased comfort level, and the decrease in size of the wound bed and tunneling indicate an improvement of the client's condition.
