Foundations Post Test

A nurse is caring for a client in the orientation phase of the nurse-client relationship. Which of the following communication techniques should the nurse use during this phase? A. Elicit information from the client B. Encourage the client to use self-exploration C. Review the client's progress toward personal objectives D. Talk with others who have information about the client

A. Elicit information from the client

A nurse is reviewing the arterial blood gas values of a client who has chronic kidney disease. Which of the following sets of values should the nurse expect? A. pH 7.25, HCO3 19 mEq/L, PaCO2 30 mmHg B. pH 7.30, HCO3 26, PaCO2 50 C. pH 7.50, HCO3 20, PaCO2 32 D. pH 7.55, HCO3 30, PaCO2 31

A. pH 7.25, HCO3 19 mEq/L, PaCO2 30 mmHg

A nurse is planning care for a client who has a decreased level of consciousness. The client is receiving continuous enteral feedings via gastrostomy tube due to an inability to swallow. Which of the following is the priority action by the nurse? A. Observe the client's respiratory status. B. Elevate the head of the client's bed 30* to 45*. C. Monitor intake and output every 8 hrs. D. Check residual volume every 4 to 6 hrs.

B. Elevate the head of the client's bed 30* to 45*.

A nurse is giving a presentation about preventing deep-vein thrombosis (DVT). Which of the following should the nurse include as a risk factor for this disorder? (Select all that apply.) A. BMI of 20 B. Oral contraceptive use C. Hypertension D. High calcium intake E. Immobility

B. Oral contraceptive use E. Immobility

A nurse is caring for several clients. For which of the following situations should the nurse complete an incident report? A. The nurse identifies a broken piece of equipment. B. A staff member does not show up to work her assigned shift. C. A client discovers that his dentures are missing. D. The nurse has a disagreement with the nursing supervisor about inadequate staffing.

C. A client discovers that his dentures are missing. This situation represents a variation from the normal standard of care. A change in the client's plan of care may be necessary if the client has difficulty eating or speaking without the dentures. In addition, the facility may be liable for replacing the missing dentures.

A nurse is caring for an older adult client who states, "I am afraid that I may fall while walking to the bathroom during the night." Which of the following actions should the nurse take? A. Limit the client's fluid intake in the evening. B. Obtain a bedside commode for the client's use. C. Leave a nightlight on in the client's room. D. Put the side rails up and tell the client to call the nurse before voiding.

C. Leave a nightlight on in the the client's room.

A nurse is preparing a sterile field. Which of the following actions should the nurse identify as contaminating the field? A. Placing a sterile dressing 2 in from the border of the sterile field. B. Holding a sterile item at just above waist level. C. Opening a sterile package over the middle of the sterile field. D. Opening the sterile tray by first unfolding the flap farthest from his body.

C. Opening a sterile package over the middle of the sterile field. Opening a sterile package over the middle of the sterile filed requires reaching into the field, which can result in contamination. The nurse should place the object on the field by approaching the field from an angle.

A nurse is caring for a client who is postoperative following an open reduction and internal fixation of a fractured femur. Which of the following actions is the most important for the nurse to complete in the postoperative period? A. Medicate the client for pain. B. Instruct the client of use of crutches. C. Perform neurovascular checks of the extremities. D. Direct the client to perform exercises of the ankle and toes.

C. Perform neurovascular checks of the extremities.

A nurse is caring for a client who has diabetes and plans to administer his regular insulin subcutaneously before he eats breakfast at 0800. After checking the client's morning glucose level, which of the following actions should the nurse take? A. Give the insulin at 0700. B. Give the insulin when the breakfast tray arrives. C. Give the insulin 30 min after breakfast with the client's other routine medications. D. Give the insulin at 0730.

D. Give the insulin at 0730.

A nurse is preparing to discontinue a client's indwelling urinary catheter. Which of the following actions should the nurse take first? A. Deflate the catheter balloon using a sterile syringe. B. Measure and document the urine in the drainage bag. C. Remove the tape or device securing the catheter to the client's thigh. D. Position the client supine.

D. Position the client supine.

A nurse checks with assistive personnel on the unit throughout the shift to determine if they are completing tasks. The nurse is demonstrating which of the following rights of delegation? A. Right circumstances B. Right communication C. Right person D. Right supervision

D. Right supervision

A nurse in a long-term facility enters the day room and finds the window curtains on fire. Clients are panicking and the room is filling with smoke. Indicate the emergency actions the nurse must take in order.

Remove the clients from the room. Activate the alarm. Close the door. Extinguish the fire.

A nurse is planning client care for herself and an assistive personnel working with her. Which of the following tasks should the nurse plan to perform? A. Administration of an enema B. Application of antiembolic stockings C. Assessing a client's sacrum for edema D. Assisting a client to cough and deep breathe

C. Assessing a client's sacrum for edema

A nurse is preparing to administer penicillin IM to an adult client. Which of the following angles should the nurse use for injection into the client's ventrogluteal muscle? A. 45 B. 60 C. 75 D. 90

D. 90

A nurse is preparing to administer an enteral feeding via nasogastric tube. Identify the correct sequence the nurse should follow to initiate the feeding.

Verify tube placement. Check the residual feeding contents. Administer the feeding. Evaluate tolerance of feeding.

A nurse is teaching a client who has a new prescription for regular insulin and NPH insulin. Which of the following instructions should the nurse include in the teaching? A. Keep the open vial of insulin at room temperature. B. Inject the insulin into a large muscle. C. Aspirate the medication prior to administration D. Administer the insulin in two separate injections.

A. Keep the open vial of insulin at room temperature.