Fundamental Nursing Knowledge

A nurse is reinforcing home safety information with an older adult client. Which of the following statements should the nurse identify as an indication that the client needs further instruction?

"I should use my walker carefully when going upstairs."

A nurse is caring for an older adult client who has constipation. Which of the following actions should the nurse take?

Add fluid and fiber to the diet.

A nurse is reviewing a provider's prescriptions for a group of clients. Which of the following client prescriptions should the licensed practical nurse (LPN) clarify with the provider?

Administer 1 g of vancomycin intrathecally.

A nurse is caring for a client who presents to an urgent care with a laceration on his forearm. Which of the following activities is an example of primary prevention?

Administering a tetanus immunization

A nurse is caring for a client who has urinary incontinence. Which of the following actions should the nurse take to prevent the development of skin breakdown?

Apply a moisture barrier ointment to the skin.

A nurse is assisting with the preparation of a presentation at a community center about complementary and alternative therapies. Which of the following therapies should the nurse describe as the use of an electronic monitoring device to help clients learn to control physical responses?

Biofeedback

A nurse is caring for a client who has a stage-3 pressure ulcer that now has some granulating tissue. Which of the following interventions should the nurse recommend for inclusion in the plan of care?

Cleanse with 0.9% sodium chloride irrigation.

A nurse is verifying that a client is giving informed consent to undergo electroconvulsive therapy. Which actions should the nurse take?

Confirm the client's signature is authentic.

A nurse is assisting in preparing a presentation at a senior center about age-related musculoskeletal changes. Which of the following alterations is appropriate for the nurse to include?

Decreased muscle mass

A nurse is contributing to the plan of care for a client who has a gastrostomy tube through which he is receiving continuous enteral feedings. Which of the following interventions should the nurse include in the plan?

Flush the tube with 30 mL of water every 4 hr.

A nurse is preparing to help with transferring a client who can partially assist to a gurney. Which of the following actions should the nurse take?

Lower the head of the bed.

A nurse is participating in an interdisciplinary treatment meeting for a client who is to go home within a week. Which of the following health care providers should the nurse identify will assist the client with activities of daily living?

Occupational therapist

A nurse is collecting data from a client who has venous insufficiency. Which of the following findings should the nurse expect?

Pitting edema

The RN has just received a client who is schedule for a subtotal thyroidectomy. The RN has just delegated to the LPN to receive the client. Which of the following interventions would the LPN defer to the RN to perform?

Provide client education.

A nurse in a long-term care 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

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

A nurse is assigned care of a client who has HIV. Which of the following infection control precautions should the nurse plan to use while caring for this client?

Standard precautions

A nurse is caring for a client who is Hindu and adheres strictly to the traditional dietary laws of this religion. The client has no other dietary restrictions. Which of the following foods should the nurse select as a component of the client's meals?

Steamed vegetables

A nurse is caring for a client who is unconscious. With the help of an assistive personnel, the nurse has repositioned the client from a left lateral to a right lateral position. The client's daughter asks why the nurse keeps her father lying on his side. Which of the following rationales should the nurse give the family member?

To prevent aspiration problems

A client with pneumonia is experiencing respiratory distress. The order states, "if respiratory distress occurs, apply a face mask with precise concentration of oxygen". Which of the following masks delivers precise oxygen concentration?

Venturi mask

Why is vitamin C in diet good for pressure ulcers?

Vitamin C is essential for wound healing to promote formation of new capillaries, synthesis of new tissue and development of collagen.

A nurse is collecting data from a client who has hypokalemia as a result of nausea, vomiting, and diarrhea. Which of the following findings should the nurse expect?

Weak, irregular pulse

what is intrathecal administration?

injected directly through the intrathecal space of the spinal cord. This should only be performed by a provider.

A nurse is assisting with a presentation about caring for clients who are receiving diuretic therapy. The nurse should explain that which of the following medications can put clients at risk for hyperkalemia?

​Spironolactone

A nurse has accepted a position on a pediatric unit and is learning more about psychosocial development. Identify the order of Erikson's stages of psychosocial development from birth through 18 years

​Trust vs. mistrust ​Autonomy vs. shame and doubt ​Initiative vs. guilt ​​Industry vs. inferiority Identity vs. role confusion

A nurse is reinforcing teaching to a group of older adults about sources of complete and incomplete protein. Which of the following foods should the nurse include as a complete protein?

​Yogurt

A nurse is reinforcing teaching with a client about the use of transcutaneous electrical nerve stimulation (TENS) to manage chronic pain. Which of the following statements by the client indicates the need for further teaching?

"It's unfortunate that I have to be in the hospital for this treatment."

A nurse working on a medical-surgical unit suspects that several clients have Clostridium difficile (C. difficile) when they all develop watery diarrhea. Which of the following actions should the nurse plan to take while waiting for the client's lab results?

Place all clients who have manifestations on contact precautions.

A nurse is contributing to the plan of care for a client who has a pressure ulcer on his heel. Which of the following information should the nurse include in the plan?

Provide the client a diet high in vitamin C.

A nurse is discussing indications for urinary catheterization with a newly licensed nurse. Which of following indications should the nurse include?

Relief of urinary retention Measurement of residual urine after urination Presence of an open perineal wound

A nurse is planning to perform passive range of motion for a client who is immobilized. Which of the following actions should the nurse plan to take?

Support extremities above and below joints.

A nurse on an inpatient mental health unit is caring for a group of clients. Which of the following actions by the nurse demonstrates the ethical concept of autonomy?

Supporting a client's wishes to refuse prescribed treatments