Fundamental of Nursing

"But you don't understand" is a common statement associated with adolescents. What is the nurse's best response when hearing this?

"It would be helpful to understand; let's talk."

A client who is suspected of having tetanus asks a nurse about immunizations against tetanus. Before responding, what should the nurse consider about the benefits of tetanus antitoxin?

A high titer of antibodies is generated

The nurse is monitoring a client's hemoglobin level. The nurse recalls that the amount of hemoglobin in the blood has what effect on oxygenation status?

A low hemoglobin level causes reduced oxygen carrying capacity

A nurse speaking in support of the best interest of a vulnerable client reflects the nurse's duty of:

Advocacy

A daughter of a Chinese-speaking client approaches a nurse and asks multiple questions while maintaining direct eye contact. What culturally related concept does the daughter's behavior reflect?

Assimilation

A client with hypothermia is brought to the emergency department. What treatment does the nurse anticipate?

Core rewarming with warm fluids

A nurse is teaching a client how to use the call bell/call light system. Which level of Maslow's Hierarchy of Needs does this nursing action address?

Safety

A nurse applies a heating pad to a client's buttocks. Upon removal of the heating pad, the nurse discovers that the client has received burns due to incorrect settings when the heating pad was initiated. Which principle would legally apply?

The nurse could be held liable for the injury that occurred

During a newborn assessment the nurse identifies that the temperature, pulse, respirations, and other physical characteristics are within the expected range. The nurse records these findings on the clinical record. Legally, how should the nurse's action be interpreted?

The nurse met the requirements set forth in the nurse practice act

The nurse recognizes that the reason the faucet handles on the sinks in a client's room are considered contaminated is because:

They are touched by dirty hands when turning the water on.

To prevent septic shock in the hospitalized client, the nurse should:

Use aseptic technique during all invasive procedures.

What is a primary purpose of evidence based nursing?

Using results from the research to improve the outcome of nursing care

A nurse is caring for a client with hemiplegia who is frustrated. How can the nurse motivate the client toward independence?

Reinforce success in tasks accomplished.

A client reports smoke coming from a utility room on the nursing unit. What is the initial action the nurse should take?

Remove anyone that is in immediate danger.

When reviewing a drug to be administered, the nurse identifies that the package insert indicates that the Z-track injection technique should be used. Under what circumstance does the nurse expect that this technique will be necessary?

Medication is irritating to subcutaneous tissue and skin.

After recovery from a modified neck dissection for oropharyngeal cancer, the client receives external radiation to the operative site. For which most critical reaction to the radiation should the nursea ssess the client

Mucosal Edema

A client is being admitted to a medical unit with a diagnosis of pulmonary tuberculosis. The nurse should assign the client to which type of room?

Negative airflow room

A nursing team leader identifies that a nurse is coming to work after drinking alcohol. What is the most appropriate way for the team leader to approach this ethical situation?

Notify the nurse manager about the problem.

A 2-year-old child admitted with a diagnosis of pneumonia was administered antibiotics, fluids, and oxygen. The child's temperature increased until it reached 103° F. When notified, the health care provider determined that there was no need to change treatment, even though the child had a history of febrile seizures. Although concerned, the nurse took no further action. Later, the child had a seizure that resulted in neurologic impairment. Legally, who is responsible for the child's injury?

Nurse, because failure to further question the health care provider about the child's status placed the child at risk

A client with hemiplegia is staring blankly at the wall and reports feeling like half a person. What is the most appropriate initial nursing action?

Offer to spend more time with the client.

The triage nurse in the emergency department receives four clients simultaneously. Which of the clients should the nurse determine can be treated last?

Older adult male with partially amputated finger

A client expresses concern about being exposed to radiation therapy because it can cause cancer. What should the nurse emphasize when informing the client about exposure to radiation?

Only a small part of the body is irritated

What is the most important factor relative to a therapeutic nurse-client relationship when a nurse is caring for a client who is terminally ill?

Personal feelings about terminal illness

A nurse is hired to work in a facility where the nurse assumes responsibility for a number of clients' needs. This nursing care delivery system is called:

Primary care nursing

How can a nurse best evaluate the effectiveness of communication with a client?

Client feedback

A recent immigrant from mainland China is critically ill and dying. What question should the nurse ask when collecting information to meet the emotional needs of this client?

Which family member do you prefer to receive information?"

An adult child of a dying client says to the nurse in the nursing home, "I am so upset because my parents always angry at me." The nurses best initial response is: "Your parents is

Working through acceptance of the situation"

A nurse is caring for a client who had head and neck surgery. Postoperatively, the nurse positions the client's head in functional alignment to prevent the complication of:

Wound dehiscence

After being medicated for anxiety, a client says to a nurse, "I guess you are too busy to stay with me." How should the nurse respond?

"I have to go now, but I will come back in 10 minutes."

A nurse is preparing a community health program for senior citizens. The nurse teaches the group that the physical findings that are typical in older people include:

Increased blood pressure and decreased hormone production

A nurse is working as a triage nurse in the emergency department. Place the following clients in the order in which they should receive care.

Infant having a seizure

The nurse is transferring a client from the bed to the chair. Which action should the nurse take during the transfer?

Instruct the client to dangle the legs.

In today's health care delivery system, a nurse as a teacher is confronted with multiple stressors. What is the major stressor that detracts from the effectiveness of the teaching effort?

Limited time to engage in teaching

A client with respiratory difficulties asks why the percussion procedure is being performed. The nurse explains that the primary purpose of percussion is to:

Loosen pulmonary secretions.

A nurse is teaching a client about gentamycin (Garamycin) that has been prescribed for a severe infection. Which statement indicates to the nurse that the client needs further teaching?

It is OK for me to stop taking this medication after a few days

A health care provider tells a client about the diagnosis of inoperable cancer and that the client does not have long to live. After the health care provider leaves, the client says to the nurse, "I feel fine. I probably only have the flu." The nurse determines that the client is in the denial stage of grief. What should the nurse do to help meet the client's emotional needs?

Allow the denial and be available to discuss the situation with the client

When suctioning a client with a tracheostomy, an important safety measure for the nurse is to:

Apply suction only as the catheter is being withdrawn.

A female client explains to the nurse that she sleeps until noon every day and takes frequent naps during the rest of the day. What should the nurse do initially?

Arrange a referral for a thorough medical evaluation

The nurse is caring for a client admitted with chronic obstructive pulmonary disease (COPD). The nurse should monitor the results of which laboratory test to evaluate the client for hypoxia?

Arterial Blood gas

A nurse is caring for a client admitted with cardiovascular disease. During the assessment of the client's lower extremities, the nurse notes that the client has thin, shiny skin, decreased hair growth, and thickened toenails. The nurse understands that this may indicate:

Arterial Insufficiency

It is appropriate for the nurse to pull up on the client's skin, release it, and determine if the skin returns immediately to its original position to assess for: Skin turgor53- The nurse is having difficulty understanding a client's decision to have hospice care rather than an extensive surgical procedure. Which ethical principle does the client's behavior illustrate?

Autonomy

A client with a leg prosthesis and a history of syncopal episodes is being admitted to the hospital. When formulating the plan of care for this client, the nurse should include that the client is at risk for:

Falls

The hospital's policy requires two nurses to supervise the wasting of excess opioid solutions. The nurse draws up the prescribed dose and then requests that another nurse witness wasting of the remaining medication. The second nurse states that there is no time to observe the wasting of the medication, enters the identification to serve as the witness, and leaves the area. What is the appropriate action for the first nurse to take?

Cancel the process and ask another nurse to serve as the witness and to observe the wasting of the medication.

A nurse is applying a dressing to a client's surgical wound using sterile technique. While engaging in this activity, the nurse accidentally places a moist sterile gauze pad on the cloth sterile field. What physical principle is applicable for causing the sterile field to become contaminated?

Capillarity

An adult client presents to the Emergency Department with a nosebleed. After applying pressure, what is the next nursing action?

Check the blood pressure

The nurse is providing post-procedure care for a client that had a central venous access device (CVAD) inserted. Before the CVAD is used, what procedure is performed to verify placement?

Chest Xray

When changing the soiled bed linens of a client with a wound that is draining seropurulent material, what personal protective equipment (PPE) is most essential for the nurse to wear?

Clean gloves

A nurse receives a shift report on four adult clients that are between the ages of 25 and 55. Which client should the nurse assess first?

Female client on warfarin (Coumadin) with an international normalized ratio (INR) of 7.5

A client is admitted with severe diarrhea that resulted in hypokalemia. The nurse should monitor for what clinical manifestations of the electrolyte deficiency? Select all that apply.

Leg cramps, muscle weakness

A client reaches the point of acceptance during the stages of dying. What response should the nurse expect the client to exhibit?

Detachment

A visitor says to the nurse, "Can I read my client's progress record? I am the sponsor from an alcohol recovery program." How should the nurse respond?

Do not allow the sponsor to review the record

The unlicensed assistive personnel (UAP) assigned to the 7 am shift has not been coming to work until 8 am. Nursing care is delayed and assignments are started late. What is the most appropriate action by the charge nurse/team leader?

Document the information before discussing it with the UAP.

A nurse advises a client to give someone the authority to make medical decisions for the client in the event that the client is unable to do so. What is the specific document that allows for this?

Durable power of attorney for health care

A nurse is reviewing a client's plan of care. What is the determining factor in the revision of the plan?

Effectiveness of the interventions

When caring for a client with venous insufficiency, the nurse would implement which nursing measure?

Elevate the clients legs above heart level

When caring for a client who is receiving enteral feedings, the nurse should take which measure to prevent aspiration?

Elevate the head of the bed between 30 and 45 degrees.

A nurse is assigned to change a central line dressing. The agency policy is to clean the site with Betadine and then cleanse with alcohol. The nurse recently attended a conference that presented information that alcohol should precede Betadine in a dressing change. In addition, an article in a nursing journal stated that a new product was a more effective antibacterial than alcohol and Betadine. The nurse has a sample of the new product. How Should the nurse proceed?

Follow the agencies policy unless it is contradicted by a healthcare provider prescription

The spouse of a comatose client who has severe internal bleeding refuses to allow transfusions of whole blood because they are Jehovah's Witnesses. The client does not have a Durable Power of Attorney for Healthcare. What action should the nurse take?

Give the spouse a treatment refusal form to sign and notify the health care provider that a court order now can be sought

A nurse manager in charge of a unit overhears two nurses in a hall filled with visitors discussing a client on the unit who has AIDS. What should be the nurse manager's initial action?

Have a conference with the nurses and talk about the need for confidentiality.

A nurse is assigned to care for a newly admitted client. The nurse performs a physical assessment and reviews the admission form and the health care provider's prescriptions. What should the nurse identify as the priorities in this client's plan of care?

Hygiene and comfort

The nurse has provided instructions about back safety to a client. Which client statement indicates understanding of the instructions?

I should carry objects close to my body

A client is admitted to the hospital for an elective surgical procedure. The client tells a nurse about the emotional stress of recently disclosing being a homosexual to family and friends. What is the nurse's first consideration when planning care?

Identifying personal feelings toward this client

The nurse teaching a health awareness class identifies which situation as being the highest risk factor for the development of a deep vein thrombosis (DVT)?

Inactivity

A nurse hired to work in a metropolitan hospital provides services for a culturally diverse population. One of the nurses on the unit says it is the nurses' responsibility to discourage "these people" from bringing all that "home medicine stuff" to their family members. Which response by the recently hired nurse is most appropriate?

You are right because they may have a negative impact on peoples health

The nurse administers a pneumococcal vaccine to a 70-year-old client. The client asks "Will I have to get this every year like I do with the flu shot?" How should the nurse respond?

"It is unnecessary to have any follow-up injections of the pneumococcal vaccine after this dose."

A 50-year-old client being seen for a routine physical asks why a stool specimen for occult blood testing has been prescribed when there is no history of health problems. What is an appropriate nursing response?

"it is performed routinely starting at your age as part of an assessment for colon cancer"

A nurse is teaching a parenting class. What should the nurse suggest about managing the behavior of a young school-age child?

Be consistent about established rules

The nurse is preparing to assess the four abdominal quadrants of a client that complains of stomach pain. When determining the order of the assessment, the nurse recognizes that it is important to assess the symptomatic quadrant:

Last

A nurse is reviewing studies to answer a clinical question as part of an evidence-based practice project. The study design determines the level of evidence. Place each methodology in order from the most reliable to the least reliable.

Meta-analysis Randomized controlled trial Cohort study Controlled trial without randomization Expert opinion based on scientific principles

The client asks the nurse to recommend foods that might be included in a diet for diverticular disease. Which foods would be appropriate to include in the teaching plan? Select all that apply.

Milk and eggs, Whole grains, Cooked fruit and vegetables

A nurse has provided discharge instructions to a client that received a prescription for a walker to use for assistance with ambulation. The nurse determines that the teaching has been effective when the client:

Moves the walker no more than 12 inches in front of the client during use

During the beginning phase of a therapeutic relationship, a clear understanding of participants roles is important because the client:

Needs to know what to expect from the relationship

A client has been diagnosed as brain dead. The nurse understands that this means that the client has:

No cortical functioning with some reflex breathing

The nurse is caring for a surgical client that develops a wound infection during hospitalization. How is this type of infection classified?

Nosocomial

The nurse has gathered data on a newly admitted client and is attempting to write the nursing diagnoses and develop a plan of care. In doing so, the nurse is aware that in the problem-etiology-signs and symptoms (PES) format:

Nursing interventions are derived from the etiology statement.

A client who was exposed to hepatitis A asks why an injection of gamma globulin is needed. Before responding, what should the nurse consider about how gamma globulin provides passive immunity?

The antigen is neutralized by the antibodies that it supplies.

A nurse is teaching staff members about the legal terminology used in child abuse. What definition of battery should the nurse include in the teaching?

The application of force to another person without lawful justification

A toddler screams and cries noisily after parental visits, disturbing all the other children. When the crying is particularly loud and prolonged, the nurse puts the crib in a separate room and closes the door. The toddler is left there until the crying ceases, a matter of 30 or 45 minutes. Legally, how should this behavior be interpreted?

The child had a right to remain in the room with the other children

An adult child of a dying client says to the nurse in the nursing home, "I am so upset because my parent is always angry at me." The nurse's best initial response is "Your parent is:

working through acceptance of the situation."

A nurse manager is informed that a community disaster drill will take place. The disaster scenario will include a bombing in a shopping mall with hundreds of casualties. What location should the nurse consider for triage of casualties when planning for this exercise? At the scene of the disaster70- At the beginning of the shift at 7 AM, a client has 650 mL of normal saline solution left in the intravenous bag, which is infusing at 125 mL/hr. At 9:30 AM the health care provider changes the IV solution to Ringer's lactate, which is to infuse at 100 mL/hr. What total amount of intravenous solution should the client have received by the end of the eight-hour shift? Record your answer using a whole number. ___ mL

863ml

When caring for a client with a fractured hip, the nurse should place pillows around the injured leg to specifically maintain:

Abduction

A dying client is coping with feelings regarding impending death. The nurse bases care on the theory of death and dying by Kübler-Ross. During which stage of grieving should the nurse primarily use nonverbal interventions?

Acceptance

Often when a family member is dying, the client and the family are at different stages of grieving. During which stage of a client's grieving is the family likely to require more emotional nursing care than the client?

Acceptance

When planning discharge teaching for a young adult, the nurse should include the potential health problems common in this age group. What should the nurse include in this teaching plan?

Accidents, including their prevention

A client experiences a muscle sprain of the ankle. When assessing the injury, the nurse discovers that a hematoma is developing, edema is present and that the client reports tenderness when the ankle is palpated. The nurse anticipates that the plan of care will include the application of a(n):

Accountability

Which of the following legal defenses is the most important for a nurse to develop?

Accountability

The nurse is preparing to perform endotracheal suctioning of a client with respiratory difficulties. Before beginning the procedure, the nurse should:

Administer 100% oxygen to the client.

The nurse recognizes that a client is experiencing an anaphylactic reaction secondary to a drug hypersensitivity. What action should the nurse take first?

Administer Oxygen

An older client asks, "How do I know that all the medications that I take are safe?" What information should the nurse include in a response to this client's question? Select all that apply.

Ask your health care provider how and when you should be taking your medications." Check the name, dose, and instructions about administration of drugs each time before leaving the pharmacy." "Inform your health care provider of the over-the-counter drugs, recreational drugs, and amount of alcohol you ingest."

When providing care for a client with a nasogastric (NG) tube, the nurse should take measures to prevent what serious complication?

Aspiration Pneumonia

The nurse should suspect that a client who had a recent myocardial infarction is experiencing denial when the client:

Attempts to minimize the illness

A nurse who promotes freedom of choice for clients in decision-making best supports which principle?

Autonomy

A nurse discusses the philosophy of Alcoholics Anonymous (AA) with the client who has a history of alcoholism. What need must self-help groups such as AA meet to be successful?

Belonging

A nurse is teaching members of a health care team how to help disabled clients stand and transfer from the bed to a chair. To protect the caregivers from injury, the nurse teaches them to lift the client by first placing their arms under the client's axillae and next:

Bending and then straightening their knees

A visitor from a room adjacent to a client asks the nurse what disease the client has. The nurse responds, "I will not discuss any client's illness with you. Are you concerned about it?" This response is based on the nurse's knowledge that to discuss a client's condition with someone not directly involved with that client is an example of:

Breach of confidentiality

A client is admitted with a suspected malignant melanoma on the arm. When performing the physical assessment, the nurse would expect to find a:

Brown or black mole with red, white, or blue areas

The nurse recognizes that which are important components of a neurovascular assessment? Select all that apply.

Capillary refill, temperature, pulse

A nurse is caring for a newly admitted client in a long-term care facility. The nurse notes that the client has a decreased attention span and cannot concentrate. The nurse suspects which effects of sensory deprivation?

Cognitive response

The nurse receives a report on a newly admitted client who is positive for Clostridium difficile. Which category of isolation would the nurse implement for this client?

Contact precautions

The nurse is preparing discharge instructions for a client who has begun to demonstrate signs of early Alzheimer dementia. The client lives alone. The client's adult children live nearby. According to the prescribed medication regimen the client is to take medications six times throughout the day. What is the priority nursing intervention to assist the client with taking the medication?

Contact the primary health care provider and discuss the possibility of simplifying the medication regimen.

When assessing an obese client, a nurse observes dehiscence of the abdominal surgical wound with evisceration. The nurse places the client in the low-Fowler's position with the knees slightly bent and encourages the client to lie still. What is the next nursing action?

Cover the wound with a sterile towel moistened with normal saline.

A nurse assesses the lungs of a client and auscultates soft, crackling, bubbling breath sounds that are more obvious on inspiration. This assessment should be documented as:

Crackles

A nurse is evaluating the appropriateness of a family member's initial response to grief. What is the most important factor for the nurse to consider?

Cultural background

Health promotion efforts within the health care system should include efforts related to secondary prevention. Which activities reflect secondary prevention interventions in relation to health promotion? Select all that apply.

Encouraging regular dental checkups Teaching the procedure for breast self-examination

A hospital has threatened to refuse the discharge of a newborn until the parents pay part of the hospital bill. The nurse is aware that the legal term that best describes this situation is:

False imprisonment

A client with COPD states, "I have had steady weight loss, and I am often too tired to eat." Which nursing diagnosis would be most appropriate for this client?

Imbalanced nutrition: less than body requirements, related to fatigue

Four days after abdominal surgery a client has not passed flatus and there are no bowel sounds. Paralytic ileus is suspected. What does the nurse conclude is the most likely cause of the ileus?

Impaired neural functioning

While the nurse moves a client from a lying to standing position, the client experiences a rapid drop in blood pressure. The nurse would report this finding as:

Orthostatic hypotension

A client with internal bleeding is in the intensive care unit (ICU) for observation. At the change of shift an alarm sounds, indicating a decrease in blood pressure. What is the initial nursing action?

Perform an assessment of the client before resuming the change of shift report

A nurse preceptor is evaluating a nurse who is preparing to administer digoxin (Lanoxin) intravenously (IV) to a client. The preceptor should stop the nurse from continuing with the procedure when the preceptor observes the nurse:

Piggybacking the digoxin in an existing infusion

Two nurses are planning to help a client with one-sided weakness to move up in bed. What should the nurses do to conform to a basic principle of body mechanics?

Position the nurses on either side of the bed with their feet apart, gather the pull sheet close to the client, turn toward the head of the bed, and then move the client.

When considering Erikson's psychosocial developmental tasks, a nurse should focus care for middle-aged adults around their need to be:

Productive

A high-protein diet is recommended for a client recovering from a fracture. The nurse recalls that the rationale for a high-protein diet is to

Promote cell growth and bone union

The plan of care for the client was to lose 7 pounds by the end of the month. The client only lost 3 pounds. The nurse should:

Reevaluate the plan of care for appropriateness

Nursing actions for the older adult should include health education and promotion of self-care. Which is most important when working with the older adult client?

Reinforcing the clients strengths and promoting reminiscing

In all states of the United States, what is the professional nurse's legal responsibility regarding child abuse?

Report any suspected abuse to local law enforcement authorities.

The nurse prepares to give a prescribed capsule of hydroxyzine (Vistaril) to a client. The client begins to vomit so the nurse holds the oral medication. The nurse has not opened the medication package. Proper and safe disposal of the capsule of hydroxyzine requires the nurse to:

Return the capsule to the pharmacy

A client, who is in a late stage of pancreatic cancer, intellectually understands the terminal nature of the illness. Behaviors that indicate the client is emotionally accepting of impending death are that the client is:

Revising the clients will and planning a visit to a friend

The nurse is assessing a group of older adults. Which should the nurse consider to be least likely to be affected by aging?

Strategies to handle stress

The nurse creates a plan of care for a client with a risk of infection. Which is the most desirable expected outcome for the client?

The client will be free of signs and symptoms of infection by discharge.

A nurse is preparing to change a client's dressing. What is the reason for using surgical asepsis during this procedure Keeps the area free of microorganisms101. A client with osteoporosis is encouraged to drink milk. The client refuses the milk, explaining that it causes gas and bloating. Which food should the nurse suggest that is rich in calcium and digested easily by clients who do not tolerate milk?

Yogurt

When permitted by the client, the nurse always should take the time to keep the family informed about what is happening to the client. The purpose of this approach is that informed families will be:

better equipped to undertake necessary family role changes