Week 1 Nursing Fundamentals

During an admission intake assessment, a nurse uses open-ended questions to gather information. An example of an open-ended question is:

"Can you tell me why your physician sent you here to be admitted?

The nurse completes the admission process of a client to an acute care facility. Which statement by the nurse demonstrates the communication technique of focusing?

"You are hoping to figure out the cause of your extreme fatigue during this hospital stay."

Paramedics arrive in the emergency department with a victim of a motor vehicle collision. The paramedic reports the driver was restrained, the car was traveling about 30 miles per hour (48 Km/hour), and the air bags were not deployed. The paramedic continues to report the car was struck from behind and that all individuals in the car were able to self-extricate. Which statement made by the nurse is verifying the report from the paramedic?

All of the victims got themselves out of the car?"

The nurse is caring for a newborn with bluish nails and lips, rapid respirations, sweating, and having difficulty feeding. Which considerations should the nurse use when assessing the blood pressure to screen for potential cardiac problems? Select all that apply

Assess blood pressure in upper extremities. • Assess blood pressure in lower extremities. • If the diastolic blood pressure continues to "0," document as the reading/P for "pulse."

The registered nurse is collaborating in the care of several medical clients. Which tasks may the nurse safely delegate to unlicensed assistive personnel (UAP)? Select all that apply.

Assessment of a client's axillary temperature Assessment of a client's radial pulse

A client has had a left-side mastectomy. How does this affect the blood pressure assessment?

Assessment of blood pressure is impeded.

When assessing a client's radial pulse, the nurse notes an irregular rhythm with a rate of 62 beats per minute. What intervention should the nurse implement next?

Auscultate the apical pulse for 60 seconds

A nurse is planning to pursue further education in the hopes of becoming an expert in geriatric nursing who carries out direct care. For which expanded career role is the nurse preparing?

Clinical nurse specialist

The nurse has finished caring for a client on contact precautions. Which nursing action regarding the stethoscope used to auscultate this client's lungs and bowel sounds is appropriate?

Disinfect it with alcohol swabs.

The registered nurse is performing a nutritional assessment to ensure that the client's diet is optimal for wound healing. The nurse's intervention can be traced back to which key contributor to nursing?

Florence Nightingale

What type of nursing program would allow a student with a 4-year degree in psychology to enter and complete a baccalaureate degree in nursing, take the NCLEX examination, and transition into a Master of Science in nursing (MSN) program?

Graduate entry program

A nurse is discussing cataract treatment with a client. Which statement by the nurse would be mosttherapeutic?

Have you ever thought of laser surgery?"

The nurse is assessing the apical pulse of a client using auscultation. What action would the nurse perform after placing the diaphragm over the apex of the heart?.

Listen for heart sounds

The nurse is caring for a client who has active tuberculosis and is under airborne precautions. The health care provider prescribes a computed tomography (CT) examination of the chest. Which action by the nurse is appropriate?

Place a surgical mask on the client and transport to the CT department at the specified time

A nurse is assessing the pulse volume of a client with influenza. The nurse notes that the client has a thready pulse. Which of the following is a description of a thready pulse?

Pulse is felt with difficulty and disappears with slight pressure.

Nurses working in bed management are assigning clients from the emergency room to semiprivate rooms. Clients with which two diagnoses are appropriate to room together, based on safety and infection control standards?

Reactive airway disease and exacerbation of chronic obstructive

Which nursing intervention would be most appropriate for a new mother that calls the nursery for help with breastfeeding?

Refer the mother for a home care visit.

A nurse in the community has been asked to join an organization based on the leadership abilities demonstrated both in the facility of employment and community-based activities. Which organization is most likely being described?

Sigma Theta Tau International

The nurse is checking the client's temperature. The client feels warm to touch. However, the client's temperature is 98.8°F (37.1°C). Which statement could explain this?

The client is covered with a couple of thick blankets.

A nurse has been caring for a client who suffered a myocardial infarction 2 days ago. During the morning assessment, the nurse asks the client how he feels. Which scenario warrants further investigation?

The client stares at the floor and states, "I feel fine."

The American Nurses Association (ANA) Standards of Professional Nursing Practice provides standard of care for all nurses. Which statement on the assessment of the nursing process is accurate?

The nurse collects comprehensive data pertinent to the client's health or situation

A nurse is explaining to a nursing student why blood pressure is a frequently used assessment parameter in a wide variety of care settings. What can be inferred from an assessment of a client's blood pressure?

The resistance that the client's heart must overcome when pumping blood

The client presents to the Emergency Department reporting fever, chills, and a productive cough. The chest x-ray shows an area of infiltrate, and the primary care provider prescribes a broad spectrum antibiotic. Which client teaching statement from the nurse is most appropriate regarding the prescribed drug?

This antibiotic is the best choice since the causative organism is not known."

The nurse is preparing to apply a prescription ointment to the client's wound. After reviewing the image, what is the most important step for the nurse to take?

Use a sterile cotton-tipped applicator to apply the prescription to the site

The nurse is communicating with a client following a routine physical examination. Which statement best demonstrates summarization of the appointment?

We reviewed your plans for your new diet and medications. Do you have any other questions?

A nurse is in charge of care for a client who has methicillin-resistant Staphylococcus aureus (MRSA). Which guideline is accurate for using transmission-based precautions when caring for this client?

Wear gloves whenever entering the client's room.

A nurse is assessing a client's nutritional intake prior to admission based upon information that indicates the client has lost 10 lb (4.5 kg) over the last 2 months. Which therapeutic communication technique is appropriate to gain information?

What factors have contributed to your weight loss over the last few months?"

The nurse conducting a hand hygiene in-service determines that the participants need additional education when they state that the use of an alcohol-based hand rub is appropriate in which situation?

When hands are visibly soiled

The nursing process is:

a critical thinking method used by nurses to provide nursing care that is individualized and holistic.

Clients demonstrating apnea have what?

a temporary cessation of breathing

A nurse is attempting to complete an admission database. While taking the history, the nurse notices the client appears uncomfortable and slightly tachypneic. The nurse should

allow the client to set the pace

Carl Rogers (1961) studied the process of therapeutic communication. Through his research, the elements of a "helpful" person were described. They include all of the following except which choice?

analysis

A client arrives at the emergency department after experiencing several black, tarry stools. The nurse will develop a cause and effect by:

asking the client if he or she has recently taken ferrous sulfate (iron) or bismuth subsalicylate.

A nurse is caring for an older adult client hospitalized following a hip fracture. Which actions by the nurse will promote the development of a therapeutic relationship? Select all that apply.

asking the client when they would like to have the bed linens changed encouraging the client to talk about the their life

An ultrasonic Doppler is used for:

auscultating a pulse that is difficult to palpate

A nurse is assessing an apical pulse on a cardiac client. The client is taking digoxin. The nurse can anticipate that the digoxin will:

decrease the apical pulse

A client has smoked most of his life and has labored respirations. He is experiencing:

dyspnea

The client is an 18-month-old in the pediatric intensive care unit. He is scheduled to have a subgaleal shunt placed tomorrow, and his mother is quite nervous about the procedure. The nurse feels for the mother and tells her that the surgeon "has done this a million times. Your son will be fine." This is an example of what type of nontherapeutic communication?

false reassurance

While communicating with a client who is hearing impaired, the nurse must take into account that the impairment serves as a:

filter.

A nurse can most accurately assess a client's heart rate and rhythm by which of the following methods?

listen with the stethoscope at the fifth intercostal space left mid-clavicular line

In the role of entrepreneur, the nurse's primary responsibility is:

managing a health-related business.

Nurse T. has auscultated Mr. Weinstein's apical pulse while a colleague simultaneously palpated his radial pulse. This assessment of Mr. Weinstein's apical-radial pulse indicates that the two values differ significantly, a finding that suggests which health problem?

peripheral vascular disease

The patient has asked the nurse to explain her WBC level of 8,000 cells/mm3. The nurse would identify the level of WBCs as:

within normal limits

A nurse is assessing a client's blood pressure manually. The nurse should identify the client's systolic blood pressure (SBP) when which event occurs?

• The first faint, but clear, sound appears.

A physician tells the nurse that nursing is a discipline, but not a profession. Which criteria should the nurse utilize to demonstrate that nursing is increasingly recognized as a profession? Select all that apply.

• Well-defined body of knowledge • Code of ethics • Ongoing research • Sets standards

A nurse needs to count a client's apical heart rate. Which assessment site is most suitable for counting the apical heart rate?

• chest

The nurse is caring for a client with a draining abscess. Which precautions will the nurse begin?

• contact

The nurse is preparing discharge instructions for a family member who will be caring for a client with an abdominal incision. Which concept should be the priority in the teaching plan?

• hand washing

Which term indicates a potentially serious client condition?

• pyrexia