Fundamental Practice B

A nurse is preparing to delegate client care tasks to an assistive personnel (AP). Which of the following tasks should the nurse delegate?

Ambulating a client who is postoperative. Ambulating a client is within the range of function of an AP. The nurse can delegate tasks to the AP that do not require special skills, assessment, or teaching.

A nurse is calculating a client's fluid intake over the past 8 hr. Which of the following items should the nurse plan to document on the client's intake and output record as 120 mL of fluid?

8 oz of ice chips The nurse should document half of the volume of ice chips when calculating fluid intake to account for the air in between the chips. The nurse should understand that 4 oz of liquid water is equal to 120 mL of fluid.

A nurse is caring for a client who requires a 24 hr urine collection. Which of the following statements by the client indicates an understanding of the teaching?

"I flushed what I urinated at 7:00 a.m. and have saved all urine since." For a 24-hr urine collection, the client should discard the first voiding and save all subsequent voidings.

A middle adult client tells the nurse, "I feel so useless now that my children do not need me anymore." Which of the following responses should the nurse make?

"People in middle adulthood often find satisfaction in nurturing and guiding young people." According to Erik Erikson, the task of middle adulthood is generativity versus self-absorption and stagnation. The focus of this task is on offering support and guidance to future generations. The nurse should explore opportunities for mastering the developmental tasks of this stage with the client, such as volunteering and mentoring young people.

A nurse in a clinic is caring for a middle adult client who states, "The doctor says that, since I am at an average risk for colon cancer, I should have a routine screening. What does that involve?" Which of the following responses should the nurse make?

"You should have a fecal occult blood test every year." Colorectal cancer screening for clients who are at average risk begins at age 50. One option for screening is a fecal occult blood test annually.

A nurse has accepted a verbal prescription "for three tenths of a milligram of levothyroxine IV stat" for a client who has myxedema coma. How should the nurse transcribe the dosage of this medication in the client's medical record?

0.3 mg The use and placement of a decimal point can potentially cause a medication error if documented incorrectly. A zero should precede a decimal point, as in 0.3 mg, but should not follow a decimal point unless a whole number follows the zero, as in 2.05 mg.

A nurse manager is overseeing the care activities on a unit. For which of the following situations should the nurse manager intervene due to a violation of HIPAA guidelines?

A nurse asks a nurse from another unit to assist with her documentation. Only health care professionals directly caring for a client should have access to the client's medical information; therefore, this is a violation of HIPAA guidelines.

A nurse is administering IV fluids to a client. When monitoring for adverse effects, which of the following assessments should the nurse identify as the priority?

Auscultate lung sounds The priority assessment the nurse should make when using the airway, breathing, circulation approach to client care is auscultating lung sounds to monitor for fluid volume excess, a complication of IV therapy. Manifestations of fluid volume excess include moist crackles in lung fields, dyspnea, and shortness of breath.

A nurse is caring for a client who has an indwelling urinary catheter. Which of the following findings indicates that the catheter requires irrigation?

Bladder scan shows 525 mL of urine. A client who has an indwelling urinary catheter should have a continuous urine flow without an accumulation of urine in the bladder; therefore, the nurse should irrigate the catheter to resolve any existing blockage.

A nurse is caring for a client who has a prescription for wound irrigation. Which of the following actions should the nurse take?

Cleanse the wound from the center outward. The nurse should clean the wound from the center outward to prevent introduction of micro-organisms from the outer skin surface.

A nurse is admitting a client who has rubella. Which of the following types of transmission-based precautions should the nurse initiate?

Droplet Droplet precautions are a requirement for clients who have infections that spread via droplet nuclei that are larger than 5 microns in diameter, including influenza, rubella, meningococcal pneumonia, and streptococcal pharyngitis.

A nurse is assessing an adult client who has been immobile for the past 3 weeks. For which of the following findings should the nurse intervene?

Erythema on pressure points Erythema on pressure points requires prompt relief of pressure and additional measures to protect the skin from breakdown.

A client who is nonambulatory notifies the nurse that his trash can is on fire. After the nurse confirms the presence of the fire, which of the following actions should the nurse take next?

Evacuate the client. According to the RACE mnemonic, the first action in response to a fire is to rescue the clients, moving them to a safe area.

A nurse is preparing to administer multiple medications to a client who has an enteral feeding tube. Which of the following actions should the nurse plan to take?

Flush the tube with 15 mL of sterile water. The nurse should flush the feeding tube with 15 to 30 mL of sterile water before administration and between each medication. The nurse should flush the feeding tube with 30 to 60 mL of sterile water following the administration of the last medication.

A charge nurse is discussing the responsibility of nurses caring for clients who have a C. difficile infection. Which of the following information should the nurse include in the teaching?

Have family members wear a gown and gloves when visiting. Nurses are responsible for ensuring that family members wear a gown and gloves to prevent the transmission of Clostridium difficile spores. Staff must also wear gowns and gloves.

A nurse is performing a Romberg test during the physical assessment of a client. Which of the following techniques should the nurse use?

Have the client stand with their arms at their sides and their feet together. A Romberg test helps identify alterations in balance. The nurse should have the client stand with their arms at their sides and their feet together to observe for swaying and a loss of balance.

A nurse is caring for a client who has recently started using a behind-the-ear hearing aid. Which of the following statements should the nurse identify as an indication that the client understands the use of this assistive device?

I will be sure to remove my hearing aid before taking a shower. Clients should remove any hearing devices before showering because exposure to water can damage them.

A nurse is caring for a client who reports difficulty falling asleep. Which of the following recommendations should the nurse make?

Maintain a consistent time to wake up each day. The client should maintain a consistent time for waking up and going to sleep. This helps to establish an internal sense of sleep and waking on a daily basis and helps to maintain it over time. This will help promote sleep for the client.

A nurse is reviewing a client's medication prescription that reads, "digoxin 0.25 by mouth every day." Which of the following components of the prescription should the nurse verify with the provider?

Medication dose In the prescription, the medication dose is not complete. The number 0.25 should be followed by a unit of measurement, such as mg, to clarify the amount the nurse should administer.

A nurse is planning teaching for a group of adolescents who each recently had surgical placement of an ostomy. Which of the following methods should the nurse use as a psychomotor approach to learning?

Practice sessions Practice sessions require psychomotor skills when learning.

A nurse is caring for a client who is receiving fluid through a peripheral IV catheter. Which of the following findings at the IV site should the nurse identify as indicating infiltration?

Skin blanching Skin blanching, edema, and coolness at the IV site indicate infiltration.

A home health nurse is completing an admission assessment of an older adult client who has their caregiver present. Which of the following findings should the nurse identify as a potential indication of elder abuse?

The caregiver insists on remaining in the room. A caregiver who refuses to leave the room during an admission assessment can be an indication of potential mistreatment of the client who is receiving care. The nurse should evaluate the client for additional signs of potential mistreatment throughout the admission assessment.

A nurse is caring for a client who has a terminal diagnosis and whose health is declining. The client requests information about advance directives. Which of the following responses should the nurse make?

We can talk about advance directives, and I can also give you some brochures about them. With this statement, the nurse offers to provide the information the client needs in a direct and simple way.

A nurse is admitting a client who has been having frequent tonic -clonic seizures. Which of the following actions should the nurse add to the client's plan of care?

Wrap blanket around all four sides of the bed. The nurse should affix linens or blankets around the head, foot, and side rails of the bed to pad them and prevent injury for a client who has been having frequent tonic-clonic seizures.

A nurse has just inserted an NG tube for a client. Which of the following findings should the nurse expect to confirm correct tube placement?

An x-ray shows the end of the tube above the pylorus. An abdominal x-ray showing the end of the tube above the pylorus indicates gastric placement.

A nurse is completing an admission assessment for a client who reports vomiting and diarrhea for the past 3 days. Which of the following findings should the nurse expect?

Rapid heart rate Tachycardia indicates fluid volume deficit, which is an expected finding for a client who has had vomiting and diarrhea for 3 days.

A nurse is teaching a client whose left leg is in a cast about using crutches. Which of the following statements should the nurse identify as an indication that the client understands the teaching?

When descending stairs, I will first shift my weight to my right leg. To descend stairs, the client should first shift his body weight to his right, unaffected leg.

A nurse is caring for a client who is refusing a blood transfusion for religious reasons. The client's partner wants the client to have the blood transfusion. Which of the following actions should the nurse take?

Withhold the blood transfusion. The principle of autonomy ensures that a client who is competent has the right to refuse treatment.

A nurse is caring for a client who reports pain. When documenting the quality of the client's pain on an initial pain assessment, the nurse should record which of the following client statements?

The pain is like a dull ache in my stomach. he client is describing the quality of the pain, which is how the pain feels in the client's own words.

A nurse is caring for a client who has decreased mobility. Which of the following actions should the nurse take to decrease the client's risk of developing plantar flexion contractures?

Apply an ankle-foot orthotic device to client's feet. The nurse should use a device to maintain dorsiflexion, such as an ankle-foot orthotic device or a foot board placed perpendicular to the mattress.

A nurse is reviewing practice guidelines with a group of newly licensed nurses. Which of the following interventions should the nurse include that is within the RN scope of practice?

Initiate an enteral feeding through a gastrostomy tube. It is within the RN scope of practice for nurses to initiate enteral feedings through nasoenteric, gastrostomy, and jejunostomy tubes.

A nurse in surgical suite notes documentation on a client's medical record that he has a latex allergy. In preparation for the client's procedure, which of the following precautions should the nurse take?

Warp monitoring cords with stockinette and tape them in place. Many monitoring devices and cords contain latex. The nurse should prevent any contact of these cords and devices with the client's skin by covering them with a nonlatex barrier material, such as stockinette, and using nonlatex tape to secure them.

A nurse is caring for a client who has terminal liver cancer. Which of the following statements should the nurse identify as an indication that the client is experiencing spiritual distress?

What could I have done to deserve this illness? The client's terminal illness might prompt the client to review their life and question its meaning. A manifestation of the client's spiritual distress is asking why this illness is happening to them.

A nurse is performing a peripheral vascular assessment for a client. When placing the bell of the stethoscope on the client's neck, the nurse hears the following sound. This sound indicates which of the following?

Narrowed arterial lumen. Blowing sounds resulting from blood flowing through occluded or narrowed arteries are known as a bruit.

A nurse in an acute care facility is preparing a discharge summary for a client who is transferring to a long-term care facility. Which of the following documentation should the nurse include?

Current medications The nurse should include the client's medications in the discharge summary to ensure client safety and continuity of care.

A nurse is planning care for a client who has tuberculosis. The nurse should use which of the following pieces of personal protective equipment when providing care for the client?

N95 respirator The nurse should wear an N95 respirator when providing care for a client who requires droplet precautions as a result of tuberculosis to prevent the transmission of bacteria.

A nurse is preparing a heparin infusion for a client who was admitted to the facility with deep-vein thrombosis. The prescription reads: 25,000 units of heparin in 0.9% sodium chloride 250 mL to infuse at 800 units/hr. At what rate should the nurse set the infusion pump?

8 Step 1: What is the unit of measurement the nurse should calculate? mL/hr Step 2: What is the dose the nurse should administer? Dose to administer = Desired 800 units/hr Step 3: What is the dose available? Dose available = Have 25,000 units Step 4: Should the nurse convert the units of measurement? No Step 5: What is the quantity of the dose available? 250 mL Step 6: Set up an equation and solve for X. HaveDesired = QuantityX 25,000 units800 units/hr = 250 mLX mL X mL/hr = 8 mL/hr Step 7: Round if necessary. Step 8: Determine whether the amount to administer makes sense. If there are 25,000 units/250 mL and the prescription reads 800 units/hr, it makes sense to administer 8 mL/hr. The nurse should set the infusion pump to administer 8 mL/hr.

A nurse is discussing the use of herbal supplements for health promotion with a client. Which of the following client statements indicates an understanding of herbal supplement use?

"I can take echinacea to improve my immune system." Echinacea is taken to promote immunity and reduce the risk of infection.

A charge nurse is observing a newly licensed nurse prepare a sterile field for a dressing change. Which of the following actions by the newly licensed nurse requires intervention by the charge nurse?

The newly licensed nurse places the cap of the sterile saline bottle on the sterile field. The newly licensed nurse should place the cap with the sterile side up on a clean surface because the outer edges are unsterile and will contaminate the sterile field.

A nurse enters a client's room and finds her on the floor. The client's roommate reports that the client was trying to get out of bed and fell over the side rail onto the floor. Which of the following statements should the nurse document about this incident?

"Client found lying on floor." The nurse should include documentation of information that is descriptive and objective concerning what the nurse actually observed, without including any opinions or judgments about motives or cause.

A nurse is teaching a group of staff nurses about the use of essential oils for aromatherapy. The nurse should include in the teaching that this therapy might be contraindicated for which of the following clients?

A client who has asthma Some essential oils can cause bronchospasm; therefore, the nurse should consult the client's provider before using this therapy for a client who has asthma.

A nurse is caring for a group of clients on a medical-surgical unit. In which of the following situations does the nurse demonstrate the ethical principle of veracity?

A client who is unaware of her recent cancer diagnosis asks the nurse if she has cancer, and the nurse responds affirmatively. Following the ethical principle of veracity, the nurse must tell the truth at all times and never deceive others.

A community health nurse is checking blood pressures for a group of clients at a community health screening. Which of the following clients is at an increased risk for hypertension?

A client who smokes one pack of cigarettes each day. A client who smokes one pack of cigarettes each day is at an increased risk for hypertension.

A nurse is planning care for a client who has vision loss. Which of the following interventions should the nurse include in the plan of care to assist the client with feeding?

Arrange food in a consistent pattern on the client's plate. Consistency in preparing the client's plate helps to facilitate self-feeding for clients who have vision loss. Staff can describe the location of the food on the plate by using a clock pattern, allowing the client to have greater independence during meals.

A nurse is preparing to transfer a client who can bear weight on one leg from the bed to a chair. After securing a safe environment, which of the following actions should the nurse take next?

Assess the client for orthostatic hypotension. The first action the nurse should take when using the nursing process is to assess the client. The nurse should determine the client's risk for falling or fainting during the transfer by assisting the client to sit and dangle the feet on the side of the bed. The nurse should assess for dizziness and a significant drop in blood pressure before assisting the client to stand and transfer into the chair.

A nurse is giving change-of-shift report about a client they admitted earlier that day who has pneumonia. Which of the following pieces of information is the priority for the nurse to provide?

Breath sounds When using the airway, breathing, circulation approach to client care, the nurse should determine that the priority information to provide is the current status of the client's breath sounds.

A nurse is providing discharge teaching for a client who has a new prescription for a home oxygen concentrator. Which of the following instructions should the nurse provide to the client and his family?

Check the cord routinely for frays or tearing Oxygen concentrators require electrical power. Safe use of this delivery system includes assessing the electrical function of the device; therefore, the nurse should instruct the client to routinely check the condition of the cord. Consider purchasing a generator for power backup Loss of electricity prevents the oxygen concentrator from functioning and could deprive the client of necessary oxygen. The nurse should also instruct the family to have the client placed on their municipality's priority list for restoring power after an outage occurs. Observe for signs of hypoxia The nurse should instruct the family to observe for and report signs of hypoxia, such as anxiety, worsening fatigue, dizziness, rapid pulse and respirations, pallor, and cyanosis. Even with supplemental oxygen, the client's status can worsen, resulting in the development of hypoxia.

A nurse on a medical unit is preparing to discharge a client to home. Which of the following actions should the nurse take as prat of the medication reconciliation process?

Compare prescriptions with medications the client received while at the facility. When performing medication reconciliation, the nurse should create a current, accurate list of every medication the client is or should be taking. Part of the process is comparing the medications the client received at the facility with those the provider has prescribed for the client to take after discharge.

A nurse is assessing a client who received an IV fluid bolus for dehydration. Which of the following findings should the nurse identify as an indication of fluid volume excess?

Distended neck veins Indications of fluid volume excess include distended neck veins, edema, tachycardia, crackles in the lungs, dyspnea, a bounding pulse, and an increase in blood pressure.

A nurse is caring for a client who has limited mobility in his lower extremities. Which of the following actions should the nurse take to prevent skin breakdown?

Have the client use a trapeze bar when changing position. By using a trapeze bar to assist with repositioning and transferring, the client avoids the friction and shearing that result from sliding up and down in bed. Shearing is a risk factor for pressure-injury development.

A nurse is preparing to administer 0.5 mL of oral single-dose liquid medication to a client. Which of the following actions should the nurse take?

Gently shake the container of medication prior to administration. The nurse should gently shake the liquid medication to ensure that the medication is mixed.

A nurse is caring for a client who is receiving pain medication through a patient-controlled analgesia (PCA) pump. Which of the following actions should the nurse take?

Instruct the family to refrain from pushing the button for the client while she is asleep. The nurse should instruct family members not to activate the button for the client while they are sleeping. Even though PCA pumps minimize the risk of overdose, toxic effects could still occur if the client receives more medication than necessary to control pain.

A nurse is caring for a client who has tuberculosis. Which of the following actions should the nurse take?

Place the client in a room with negative-pressure airflow The nurse should place the client in a room with negative-pressure airflow to meet the requirements of airborne precautions. Wear gloves when assisting the client with oral care The nurse should wear gloves when assisting the client with oral care to meet the requirements of standard precautions, which the nurse must adhere to for all clients regardless of their diagnosis. The nurse should wear gloves whenever their hands might come in contact with a client's bodily fluids, such as saliva, and the mucous membranes in the mouth. Use antimicrobial sanitizer for hand hygiene The nurse should use antimicrobial sanitizer for routine hand hygiene when caring for a client who has tuberculosis. Nurses should also wash their hands with soap and water when their hands are visibly soiled.

A nurse is reviewing protocol in preparation for suctioning secretions from a client who has a new tracheostomy. Which of the following actions should the nurse plan to take?

Select a suction catheter half the size of the lumen. The nurse should select a suction catheter that is half the size of the lumen to prevent hypoxemia and trauma to the mucosa.

A nurse is caring for a client who has an NG tube and is receiving intermittent feedings through an open system. Which of the following actions should the nurse take first?

Tell the client to keep the head of the bed elevated at least 30 degree. The first action the nurse should take when using the airway, breathing, circulation approach to client care is to prevent aspiration of the enteral formula; therefore, the priority intervention is to keep the head of the bed elevated at least 30° to prevent reflux of the formula into the esophagus.

A nurse is caring for a client who has a prescription for 5 units of regular insulin and 10 units of NPH insulin to mix together and administer subcutaneously. Determine the correct order of steps for this procedure.

The nurse should first inject air into the vial of NPH insulin without touching the needle to the solution. Next, the nurse should inject air into the vial of regular insulin and withdraw the correct amount of the regular insulin. Finally, the nurse should insert the needle into the NPH insulin vial and withdraw the correct amount of NPH insulin. The nurse should follow these steps to prevent contaminating the regular insulin with NPH insulin.

A nurse is preparing to obtain a lower extremity blood pressure from a client and no longer palpates the popliteal pulse after 92 mmHg. Which of the following images displays the measurement in mmHg to which the nurse should inflate the cuff when obtaining the blood pressure?

To obtain an accurate blood pressure measurement, the nurse should inflate the cuff 30 mm Hg beyond the point at which the nurse was last able to palpate the pulse. If the nurse last palpated the pulse at 92 mm Hg, then this would be the correct pressure to which the nurse should inflate the cuff.

A nurse is teaching an older adult client who is at risk for osteoporosis about beginning a program of regular physical activity. Which of the following types of activity should the nurse recommend?

Walking briskly Weight-bearing exercises are essential for maintaining bone mass, which helps to prevent osteoporosis. Walking engages older adult clients in this preventive and therapeutic strategy.

A nurse is caring for a client who requires an informed consent for a surgical procedure. Which of the following actions is the nurse's responsibility?

Witness the client's signature on the consent form. The nurse is responsible for witnessing the client sign the consent form. The nurse should confirm that the client appears competent to give consent and that the client understands the procedure.

A nurse is planning an educational program for a group of older adults at a senior living center. Which of the following recommendations should the nurse include?

You should receive a pneumococcal vaccine when you are 65 years old. The nurse should instruct older adult clients to receive one of the two pneumococcal vaccines when they are 65 years old. The vaccines can be given to clients who are 19 years of age and older and have certain conditions, such as chronic heart, lung, or liver disease, diabetes mellitus, and alcohol disease, or to those who smoke cigarettes.