Foundations practice questions

A nurse is caring for a client who is experiencing respiratory distress. Which of the following early manifestations of hypoxemia should the nurse recognize?

-Pale skin -Elevated blood pressure

A nurse is caring for a client who fell at the nursing home. the client is oriented to person, place, and time and can follow directions. Which of the following actions should the nurse take to decrease the risk of another fall?

-make sure the clients call light is within reach -provide the client with nonskid footwear -complete a fall risk assessment

a nurse is caring for a client who has crohns disease and is on a low residue diet. which of the following foods should the nurse provide the client as a snack?

1 cup of pasta

a nurse is caring for a client who is recieving oxygen at 8L/min through a simple face mask. the nurse should identify that the client is able to receive which of the following concentrations of oxygen with a simple face mask?

40%

You will use the concept of primary prevention when instructing a patient to:

Get a flu shot every year

a nurse receives a telephone call from a clients sister requesting information about the clients status. which of the following statements should the nurse make?

I will check with your brother to see if he has given permission for you to receive information about his status

A nurse is planning care for four clients. Which of the following tasks should the nurse delegate to a licensed practical nurse (LPN)?

Perform a wet to dry dressing change for a client who has a pressure ulcer

Sally has decided to set aside 30 minutes a day to walk after work next week. Sally is in what stage of risk factor modification?

Preparation

According to Maslows hierarchy of needs, which of these needs would the patient seek to meet first

Shelter

A nurse is planning care for a client who has residual effects from an ischemic stroke. Which of the following interprofessional consults should the nurse request first?

Speech language pathologist

a nurse is conducting medication reconciliation for a client who is a new admin to the facility. which of the following actions should the nurse take first?

ask the client which herbal supplements he takes

a nurse is caring for a client who has respiratory acidosis. which of the following medications should the nurse prepare to administer?

bronchodilator

a nurse is admitting a client who has pneumonia and is reviewing the clients medication prescriptions. the nurse should identify which of the following medications as the priority to administer?

clarithromycin

a charge nurse is delegating client care for the oncoming shift. which of the following tasks should the nurse delegate to assistive personnel?

collecting vital signs for a client who is on contact precautions

When caring for a patient who has multiple health problems and related medical diagnoses, nurses can best perform nursing diagnoses and nursing interventions by developing a :

concept map

A newly admitted patient states that he has recently had a change in medications and reports that stools are now dry and hard to pass. This type of bowel pattern is consistent with?

constipation

a nurse is assessing a client who is post op following abdominal surgery and discovers bowel protruding from the clients incision. which of the following actions should the nurse take first?

contact the rapid response team

a nurse is assessing a client who is post op following abdominal surgery and discovers the client has bowel protruding from the incision. which of the following actions should the nurse take?

cover the wound with a nonadherant dressing

Information regarding a patients health status may not be released to non health care team members because:

legal and ethical obligations require health care providers to keep information strictly confidential

a nurse is documenting information about a client at a computer terminal in the nurses states when she has to leave the area to respond to a clients call light. which of the following actions should the nurse take?

log out of the computer before leaving the area

a nurse is documenting assessment findings on a client in the computer when an assistive personnel (AP) asks to use the computer to enter shift vital signs. Which of the following actions should the nurse take?

log out so the AP can use the computer

A surgical wound requires a hydrogel dressing. the primary advantage of this type of dressing is that it provides:

moisture needed for wound healing

a nurse is promoting independence at meal time for a client who has vision impairment. which of the following interventions should the nurse implement?

reference to the face of a clock to indicate where the food is placed on the plate

A nurse is caring for a client who has a new diagnosis of lyme disease. the client states, ive decided on a therapy plan but I wish I knew how this happened to me! I always take good care of myself. which of the following responses should the nurse make?

you say youve made a decision about treatment although you seem to be focusing on how it couldve been prevented

a nurse on a med surge unit is providing discharge instructions to a client when he asks for a copy of his medical record. which of the following statements should the nurse make?

you will have to sign a request form for me to help get a copy for you

a nurse is preparing a client who is scheduled for a laparoscopic cholecystectomy. the client states, I have changed my mind. i dont want the surgery. which of the following responses should the nurse give?

I will let the provider know about your decision

A nurse is managing the care for a client who has recent unexplained weight loss and a low serum albumin level. Which of the following members of the interprofessional care team should the nurse consult?

Registered dietician

a nurse is implementing priority based interventions for a group of clients. which of the following clients should the nurse see first?

a client who has a cast on a compound fracture and has an SaO2 of 88%

A nurse is receiving change of shift report for a group of clients. Which of the following clients should the nurse attend to first?

a client who has received nitroglycerine sublingual for chest pain and requires a 12 lead EKG

a nurse caring for four clients who are 4 days post op following abdominal surgery. the nurse should further assess which of the following clients for a wound evisceration?

a client who reports feeling his incision separate when he sneezed

a charge nurse is teaching a class about the principles of delegation to a group of staff nurses. Which of the following information should the nurse include in the teaching

a delegator should delegate tasks that have predictable outcomes

A patient you are assisting has fallen in the shower. You complete an incident report. The purpose of an incident report is to:

aid in the hospitals quality improvement program

a nurse is teaching a client who has a prescription for phenytoin. the nurse should inform the client that which of the following medications can decrease the effectiveness of phenytoin?

aluminum hydroxide

During a teaching session, the nurse tells a patient with a recent neck injury that damage to the nerves is comparable to a water hose that has been pinched off. During this teaching session, the nurse is using the process of:

analogy

the nursing assistant asks you the difference between a wound that heals by primary or secondary intention. Your reply that a wound heals by primary intention wen the skin edges are:

approximated

a nurse is admitting a client who reports increased thirst and fatigue. which of the following actions should the nurse include in the assessment step of the nursing process?

ask the client when the condition started

a nurse at the community mental health center is teaching a group of clients about fluoxetine. the nurse should inform the clients that which fo the following meds interacts adversely with fluoxetine?

aspirin

a nurse is preparing to administer medication to a client. which of the following client identifier should the nurse use to ensure safe practice?

barcode on the clients wristband

a nurse is planning to administer medication to a client. which of the following should be the last check the nurse completes when reviewing the medication against the MAR?

before admin to the client

a charge nurse is assigning client care for the oncoming shift. which of the following tasks should the nurse assign to an RN?

calling a client to evaluate his condition 24 hr following discharge

A nurse is following the steps of the nursing process when caring for a group of clients. Which of the following actions by the nurse demonstrates the evaluation step of the nursing process?

check and document a clients pain level 30 minutes after administering pain meds

a nurse on a med surge unit is administering meds to a client. which of the following actions should the nurse take?

checking the clients mouth to ensure that he has swallowed the medications

a nurse is collecting a medication history from a client who has a new prescription for cyclosporine. the nurse should recognize that which of the following client meds can interact with cyclosporine?

cimetidine

a nurse is preparing a plan of care for a client who is experiencing pain after surgery. Which of the following components should the nurse identify as part of the planning step of the nursing process?

formulate client goals for prioritized problems

a nurse in full PPE is preparing to leave the room of a client in isolation. which of the following PPE items should the nurse remove first

gloves

a nurse is preparing to administer acetaminophen 1,000 mg PO every 12 hr for a client who has arthritic pain. the nurse should monitor the client for which of the following adverse effects?

hepatotoxicity

A nurse in the emergency department is completing a health history for a client who has diabetes mellitus. which of the following questions should the nurse ask the client to assess his understanding of the primary health problem?

how has your illness altered your typical daily acitivities?

a nurse is caring for a client who has a prescription for spironolactone and losartan. when considering the potential interactions between these meds, the nurse should monitor the client for which of the following adverse effects?

hyperkalemia

Which of the following is the first step of the research process?

identify a problem

a nurse is caring for a client who has a fractures humerus and received an opioid medication IV 1 hour ago for pain. which of the following questions should the nurse ask to determine the intensity of the clients pain at this time?

on a scale of 0-10 how do you rate your pain?

a nurse is assisting a client who is at risk for aspiration following a stroke with eating. which of the following actions should the nurse take?

palpate the clients throat while they are swallowing

a nurse is preparing to exit the isolation room of a client who has disseminated varicella zoster virus which requires airborne precautions. which of the following action should the nurse take?

remove the first glove by grasping the lower portion of the glove with the opposite hand and pulling it off inside out

a nurse is preparing to administer medication to a client using the medication bar scanning method. Which of the following actions should the nurse take first?

scan the clients ID bracelet

a nurse is caring for a client who has a left hip fracture and is prescribed a morphine IV bolus as needed for pain. the nurse should monitor for which of the following adverse effects?

sedation

a nurse is preparing to administer ciprofloxacin to a client when the client tells the nurse he is not going to take it. which of the following responses should the nurse make?

this is the antibiotic your provider prescribed to treat your infection

a nurse is evaluating an APs understanding of isolation precautions. which of the following actions by the AP indicated an understanding of isolation precautions?

using a separate urinary measuring container to empty a clients urinary catheter drainage bag

A nurse has prepared a sterile field for assisting a provider. Which of the following events should the nurse recognize as contaminating the sterile field?

-the nurse moistens a cotton ball with sterile normal saline and places it on the sterile field -the procedure is delayed 1 hr because the provider receives an emergency call -the nurse turns to speak to someone who enters through the door behind the nurse

a nurse is preparing to administer bumetanide to a client who has heart failure. for which of the following findings should the nurse withhold the medication and contact the provider?

BP 84/50

a nurse is preparing an educational program for a group of staff nurses about transmission precautions. which of the following instructions should the nurse include?

a nurse should use airborne precautions when caring for a client who has TB

a nurse is reviewing the medication administration record of a client who has difficulty swallowing. which of the following medications should the nurse identify as safe to crush before admin to the client?

acetaminophen caplet

a charge nurse is assigning client care for the oncoming nursing shift. Which of the following tasks should the nurse assign to an LPN?

administering a tube feeding to a client who has an established gastronomy tube

A nurse is caring for a client who has a history of falls. which of the following actions is the nurses priority?

complete a fall risk assessment

a nurse is assessing a client who is receiving oxygen via partial rebreather mask at 10 L/min. when auscultating the clients lungs, the nurse should monitor for which of the following findings as an indication of oxygen toxicity?

crackles

a nurse is caring for a client who has been placed on a full liquid diet. which of the following foods should the nurse offer the client?

cream of chicken soup

The nursing process organizes your approach while delivering nursing care. To provide the best professional care to patients, nurses need to incorporate the nursing process and:

critical thinking skills

a nurse is caring for a client who is 1 hr post op following an open cholecystectomy with general anesthesia. the nurse should monitor for which of the following findings as an indication of hypoxia?

cyanotic mucous membranes

a charge nurse is planning to delegate client care to a nurse. which of the following actions should the nurse plan to take first?

determine client care requirements

a nurse on a mental health unit is admitting a client who has generalized anxiety disorder. which of the following tasks should the nurse plan to include in the orientation phase of the relationship between the client and the nurse?

develop a contract with the client about how private information will be handled

a nurse is preparing to administer the first dose of clarithromycin to a client who has pneumonia. for which of the following adverse reactions should the nurse monitor?

diarrhea

A nurse is planning care for a client who is on bedrest. Which of the following interventions should the nurse plan to implement?

encourage the client to perform antiembolic exercises every 2 hrs

A nurse in a rehabilitation facility is performing the role of a case manager for a group of clients. Which of the following actions should the nurse take?

ensure clients receive optimal care in a cost effective manner

The use of diagnostic reasoning involves a rigorous approach to clinical practice and demonstrates that critical thinking cannot be done:

haphazardly

a nurse is caring for a client who has metabolic alkalosis. as the client compensates for this acid base imbalance, which of the following mechanisms should the nurse expect the clients body to use?

hypoventilation

A young girl is having a problem urinating postoperatively. You remember that children may have trouble voiding/?

in the presence of a person other than one of their own parents

Every health care organization gathers data on health outcomes. Examples of data include:

infection rates

A nurse is caring for a group of clients. Which of the following actions by the nurse demonstrates the use of critical thinking skills?

intervene after reviewing arterial blood gas results for a client who is on mechanical ventilation

A postoperative patient arrives at an ambulatory care center and states, I am not feeling good. Upon assessment, you note an elevated temperature. An indication that. the wound is infected would be:

it shows purulent drainage coming from the incision site

A charge nurse is reviewing the facilities confidentiality policies and procedures when accessing a clients personal health information with a newly licensed nurse. Which of the following actions requires intervention by the charge nurse?

leaves an active computer screen unattended

to maintain normal elimination patterns in the hospitalized patient you should instruct the patient to defecate 1 hr after meals because?

mass colonic peristalsis occurs at this time

a nurse is preparing to administer a medication that he is unfamiliar with to a client. which of the following resources should the nurse identify the therapeutic use of the medication?

medication reference book

a nurse is assessing a client who has acute alcohol intoxication. the nurse should identify that the client is at risk for which of the following acid base imbalances?

metabolic acidosis

a nurse is caring for a client whose ABG results are pH 7.30, PaCO2 32 mm hg, and HCO3- 19 mEq/L. the nurse should identify that the client has which of the following acid base imbalances

metabolic acidosis

a nurse is admitting a client who has a history of type 2 diabetes mellitus following a CT scan with contrast to diagnose the presence of renal calculi. the nurse should expect to withhold which of the following of the clients home medications?

metformin

a nurse is teaching a client about advanced directives. which of the following statements by the client indicated an understanding of the teaching?

my living will addresses whether or not I want to receive CPR

A nurse records that the patient states his abdominal pain is worse now than last night. This is an example of:

narrative charting

A nurse has just admitted a patient with a medical diagnosis of congestive heart failure. When completing the admission paper work, the nurse needs to record:

objective data that is observed

A nurse is planning care for a group of clients. Which of the following tasks should the nurse identify as requiring the use of informatics?

obtaining a clients O2 sat

a nurse is creating a plan of care for an older adult client who has a hearing impairment. which of the following communication strategies should the nurse plan to use to enhance verbal dialogue with the client?

pause between sentences to verify the clients understanding

Consultation occurs most often during which phase of the nursing process?

planning

A nurse is caring for a client who has been sitting in a chair for 1 hr. which of the following complications is the greatest risk to the client?

pressure injury

a nurse on a quality management team is developing written educational materials for clients who have varying degrees of health literacy. Which of the following strategies should the nurse include to aid the clients in effective learning?

provide instructional materials to the client that focus on desired behavior rather than just medical facts

a nurse is planning care for a client who is having difficulty swallowing food at mealtime. which of the following interventions should the nurse include in the plan of care?

provide oral hygiene before a meal

a nurse in a long term car facility is planning care for a client who is to receive oxygen at 4 L/min via nasal cannula. which of the following interventions should the nurse include in the plan of care?

provide the client with oral care every 8 hr

A patient newly diagnosed with diabetes needs to learn how to use a glucometer. Use of a glucometer constitutes:

psychomotor learning

a nurse finds a used needle and syringe in a treatment area. in attempting to dispose of the needle safely, the nurse incurs an accidental needle stick. after the nurse identifies who used the needle and syringe for which client, which of the following actions is within the nurses rights?

receiving information about the results of the clients test for blood borne pathogens

a nurse steps into an outdoor employee dining area and overhears two staff members talking about a client having an upsetting visit with his partner earlier in the day. which of the following actions should the nurse take?

remind the staff members that discussing a client where others can overhear them is a HIPAA violation

a nurse is contributing to the plan of care for a client who has a wound infection and requires contact precautions. which of the following actions should the nurse include in the plan of care?

remove the isolation gown before leaving the clients room after providing direct care to the client

a nurse is caring for a client who has a high fever and is hyperventilating. his ABG results are pH 7.51, PaCO2 28 mm hg, and HCO3- 24 mEq/l. the nurse should identify that the client has which of the following acid base imbalances.

respiratory alkalosis

A nurse is admitting a client who has an infected leg wound. the client states that he was treated 1 month earlier for the same condition. Which of the following actions should the nurse take?

review the clients data for treatment in the computer

After evaluating a patients external variables, the nurse concludes that health beliefs and practices can be influenced by:

socioeconomic factors

a nurse is preparing to administer hydrocodone to a client who reports throbbing pain following a back injury. the nurse should document that the client is experiencing which of the following types of back pain?

somatic

a nurse is teaching a client who is post operative following abdominal surgery. which of the following instructions should the nurse include to reduce the risk for wound evisceration?

support your abdomen with a pillow when coughing

a nurse is preparing to obtain informed consent for a child who fell and broke her arm. since the childs parents are not present and cannot be reached, which of the following individuals should the nurse identify as able to provide consent for the child?

the childs grandparents

a nurse is assessing a client who is postoperative following abdominal surgery. the nurse should identify that which of the following findings increases the risk for wound evisceration?

the client is morbidly obese

A nurse has removed a sterile pack from its outside cover and placed it on a clean work surface in preparation for an invasive procedure. Which of the following flaps should the nurse unfold first?

the flap farthest away from the body

A patient is suffering from shortness of breath. The correct goal statement would be written as:

the patient will breathe unlabored at 14-18 BPM by the end of the shift

a nurse is planning care for a client who requires an exact concentration of oxygen. which of the following oxygen delivery systems should the nurse use?

venturi mask

a nurse at a providers office is reviewing the medication record of a client who reports taking acetaminophen 1500 mg daily for muscle aches. the nurse should recognize that which of the following client medications interacts adversely with acetaminophen?

warfarin

a nurse is assessing a clients pain. which of the following questions should the nurse ask the client to assess the quality of pain

what does your pain feel like?

a nurse is assisting with obtaining informed consent for a client who will undergo surgery in the morning. which of the following actions should the nurse take?

witness the client voluntarily signing the consent form