Fundamentals 402 Questions Practice for Final

A nurse is collecting a specimen for culture from a clients infected wound. WHich of the following actions shoudl the nurse perform?

Cleanse the wound with .09% sodium chloride irrigation

A nurse is caring for a client who has a terminal illness. Which of the following findings indicates that the clients death is imminent?

Cold extremities

A nurse is preparing to administer liquid medication from a bottle to a client. Which of the following actions should the nurse take?

Hold the medication bottle with the label against the palm of the hand when pouring

A nurse is caring for a client who has a stage II pressure ulcer. WHich of the following wound dressings should the nurse apply to the ulcer>

Hydrocolloid

A nurse is caring for client who has injuries resulting from a motor vehicle crash. Which of the following client statements should the nurse address first

I cant sleep well because whenever move in my sleep the pain works me up

A nurse is performing a spiritual assessment of a client. Which of the following questions should the nurse ask?

"What is your source of strength and hope?

A community health nurse is conducting a class about body mechanics for county office workers. WHich of the following instructions should the nurse include?

-Sit with your back supported -Keep your hips at knee level -use an ergonomically designed computer keyboard

A nurse is assessing the Ph of a clients gastric fluid to confirm the placement of the NG tube in the stomach. WHich of the following PH values should the nurse expect

2

A nurse is providing teaching to a client about nutritious diets to a group of patients about a group of adult women. Which of the following statements should the nurse include

2.5 cups of vegetables

A nurse is explaining the use of written communication consent forms to a newly licensed nurse. The nurse should ensure that a written consent form has been signed by which of the follwoign clients?

A client who has a prescription for a transfusion of packed red blood cells

A nurse is caring for a client who is postop and has paralytic ileus. Which of the following abdominal assessments should the nurse expect

Absent bowel sounds with distention

A nurse asks a client to explain the statement: " A bird in the hamd is worht more than two in the bush"

Abstract reasoning

A nurse is supervising a newly licensed nurse who is suctioning a clients tracheostomy. WHich of the following actions by the newly licensed nurse indicates an understanding of the procedure

Administering high flow oxygen prior to the procedure

A nurse is caring for a client who states that she does not want to get out of bed due to pain from arthritis. WHich of the following should the nurse take?

Advise the client to perform range of motion exercises while in bed

A nurse is admitting a client who has TB. In addition to standard precautions, which of the following transmission bases precautions should the nurse add to the clients plan of care

Airborne

A nurse is admitting a client who has measles. WHich of the following types if transmission precautions should the nurse initiate?

Airborne

A nurse on a surgical a client who had abdominal surgery from the postanesthesia care unit. Which of the following assessment should the nurse make first?

Airway

A nurse in a urgent care center is caring for a 15 yr client who symptoms suggest an STI. The client's patient is unavailable, but the clients grandmother accompanied the client to the client to the clinic. WHich of the follwoing actions should the nurse take?

Ask the adolescent to sign the consent form

A nurse is performing a focused assessment of a clients peripheral vascular system. In which of th following locations should the nurse palpate the posterior tibial pulse

Below the medial malleolus

A nurse is administering medication to a client who asks the nurse to leave the medication at bedside to be taken at a later time. WHich of the following responses should the nurse make?

Call me when you are ready and I will return the medication

A nurse is beginning her shift and reviewing the medication administration record for her clients. SH enotes a dosage of medication above the safe range and sees that a nurse administered that dosage during that orevious shift. WHich of the follwoing actions should the nurse take?

Call the doctor to clarify the dosage

A nurse enters a client's room and finds the client sitting on the floor and leaning against the side of bed. The client states she slipped while getting out of bed. Which of the following actions should the nurse take first?

Check client for injuries

A nurse is implementing cold therapy for a client who has an ankle sprain. Which of the following actions should the nurse take?

Check the cap refill before applying an icepack to the affected area

A nurse is caring for a client who has a major fecal incontinence and reports irritation in the perineal area. Which of the following actions should the nurse take first?

Check the clients perineum

A nurse is caring for a client who was transferred to the surgical unit by stretcher from the PACU. Which of the following actions should the nurse perform immediately following the transfer?

Check the clients vital signs

A nurse documents the presence of clubbing of the fingernails for a client who has emphysema. Which is the underlying cause of this finding

Chronic hypoxemia

A nurse is preparing to assess the function of the clients trigeminal nerve. WHich of the following should the nurse gather for the test

Cotton wisps

A nurse is caring for a client who is immobile. The nurse should recognize that immobility places the client at risk of which of the following health alterations

Decreased cardiac output

A nurse is replacing the surgical dressing on a client who had abdominal surgery. Which of the following actions should the nurse take?

Don clean gloves to remove old dressing

A nurse is caring for a client who has MRSA infection. A dietary assistant asks the nurse what precautions are ner=cessary for entering the clients room with the lunch tray. WHich of the follwoing instructions should the nurse give to the dietary assisstant

Don gloves when enetering and hand sanitizer when exciting

A nurse is preparing to administer eyedrops to a client following surgery. WHich of the following actions should the nurse take when instilling the eyedrops

Drop the med into the lower conjuctival sac

A home health nurse is planning to provide health promotion activities for a group of clients in the community. Which of the following activities is an example of primary preventing?

Educating clients about the recommended immunization schedule for adults

A nurse is caring for an adult client who has an NG tube in place and a prescription for continuous enteral feedings. WHich of the following actions should nurse perform to reduce the clients risk for aspiration?

Elevate the head to 30 or 45 degrees

A nurse is performing eye irrigation for a client who was exposed to smoke and ash. WHich of the following should the nurse take

Exert pressure on the bony prominences when holding the eyelids open

A new resident asks the charge nurse for an access code to review clients online records. The resident is not scheduled to attend the facilitys orientation computer class until next week. WHich of the following actions should the nurse take?

Explaing that it is against policy to share access codes and refer the resident to his supervisor

A nurse is teaching a middle-aged client about disease prevention and health maintenance. Which of the following diagnostic tests should the nurse recommend as part of the clients routine health screening?

Eye examination every 2 years

A nurse is performing a physical assessment of a client. The nurse should recognize that which of the following findings places the client at risk of impaired skin intergrity?

Faint pedal pulses

A nurse is performing a comprehensive physical assessment of a client. The nurse should inspection to assess which of the following?

Gait

A nurse is assessing a client who is experiencing an obstruction of the flow of the vitreous humor in the eye

Glaucoma

A nurse is preparing to change the bed linens of a client who has aids and is incontinent of stool. Which of the PPE items should the nurse don prior to providing client care

Gown and gloves

A nurse is teaching a client how to self administer insulin. WHich of the following actions should the nurse take to evaluate the clients understanding of the process within the psychomotor domain of learning

Have client demonstrate

A nurse is caring for a client with dehydration who has developed hypovolemic shock. Which of the following laboratory values should the nurse expect for this client?

Hct 55%

A nurse in a same day procedure unit is caring for several clients who are undergoing doifferent types of procedures. The nurse should anticipate that the client who has which of the following devices can safely can ungergo MRI

Hearing aids

A nurse is preparing to administer an otic antibiotic to an adult client who has otis media. WHich of the follwoign actions should the nurse plan to take?

Hold the dropper 1 cm above ear canal

A nurse is teaching a client who is postoperative about the importance of turning, cough, and breathing deeply. WHich of the following statements should the nurse identify as an indication that the client understands the instructions?

If i do this often, I wont get pneumonia

A nurse is reviewing the use side rails with an AP. WHich of the following statements by the AP indicates that further teaching is required

If the client seems confused, ill raise all 4 rails so that he doesnt hurt himself

A nurse is assessing a client who reports nausea and vomitting for two days. Which of the following findings should indicate to the nurse that the client is experiencing fluid volume deficit

Increased heart rate

A nurse is performing a breast examination for a female client. WHich of the follwoign techniques should the nurse use first?

Inspect both breasts simultaneously

A nurse is planning to assess the abdomen of a client who reports feeling bloated for several weeks. Which of the following methods of assessment should the nurse use first?

Inspection

A client who has glaucoma of the right eye self-administers timolol eye drops by looking at at the celiening and instilling a drop onto the center of the conjuctival sac, and applying gentel to the lower lid with a facial tissue. AFter observing this process, which of the following actions should the nurse take?

Instruct the client to apply pressure to the inside corner of the eye after instillation

A nurse is an acute facility is planning care for a client who is alert but temporarily immobile due to a total hip arthroplasty. WHich of the following interventions should the nurse plan to take to prevent a complication of immobility

Instruct the client to perform foot and leg exercises every 1-2 hr to awake to help prevent thrombophlebitis

A nurse is caring for a client who has a temp of 101.7. WHich of the following actions should the nurse take?

Keep the clients bed linens dry

A nurse is providing teaching to a client regarding protein intake. WHich of the following foods should the nurse include as an example of an imcomplete protein

Lentils

A nurse in a provider's office is collecting information from an older adult client who reports taking acetaminophen for 500 mg/day for severe joint pain. The nurse should instruct the client that large doses of acetaminophen could cause which of the following adverse effects

Liver damage

A nurse is caring for a client who starts to experience a seizure while sitting in a chair. WHich of the following actions should the nurse take?

Lower the client to the floor and place a pad under the clients head

A nurse is admitting a client who has a hearing aid. Which of the following actions should the nurse take before the interview process?

Make sure the device is funtioning

A nurse in the emergency department is assessing a client who has depe rapid respirations. ABG analysis includes the following values ph7.25 PaCo2 40 and HCO 18

Metabolic acidosis

A nurse is preparing a client who is scheduled for a hysterectomy for transport to the operating room. The client states she no longer wants to have the surgery. WHich of the following actions should the nurse take?

Notify the provider

A client who reports shortness of breath requests the nurses's help in changing positions. After repositioning the client, which of the follwoign actions should the nurse take next?

Observe the rate, depth and character

During th insertion of a urinary catheter for a client, the tip of the catheter brushes against the nurses arm. WHich of the following actions should the nurse take?

Obtain a new catheter and reattempt insertion

A nurse on a med surg unit is caring for a client. Which of the following actions should the nurse prioritize when using the nursing process

Obtain client information

A nurse is planning discharge teaching to a client who does not speak the same language as the nurse. The client's neighbor, who speaks both the client's native language and the nurse's, arrives to to drive the client home. Which of the following actions should the nurse take?

Obtain the services of an interpreter

A nurse is performing a physical assessment of a client. Which of the following actions should the nurse take to assess the client's tissue perfusion?

Perform a blanch test

A nurse is preparing to remove an NG tube for a client who had a partial colectomy. Which of the following actions should the nurse take?

Pinch the NG tube while removing the tube

A nurse is caring for a client who reports feeling a pop after coughing without properly splinting an abdominal incision. On assessment, the nurse nothes that the clients wound has been eviscerated. Which of the following actions should the nurse take?

Place in supine with hips and knees flexed Cover the wound and intestine with a sterile moistened dressing Monitor for shock

A nurse is leading an education session about disposing of biohazardous material which of the follwoing instructions should the nurse include in the teaching?

Place soiled linen in a single linen bag

A nurse on a rehab unit is preparing to transfer a client who is unable to walk from a bed to a wheelchair. Which of the following should the nurse use?

Place wheelchair at 45 degree angle

A nurse is preparing to perform postural drainage for a client. Which of the following actions should the nurse take?

Position the client for drainage of secretions by gravity.

A nurse is caring for a client who is receiving intermittent enteral feedings through an NG Tube. The specific gravity of the clients using 1.035. Which of the following actions should the nurse take

Provide more water with feedings.

A nurse is changing the dressing for a client who is 3 days post op following a cholecystomy. The nurse observes yellow, thick drainage on the dressing. The nurse should document this finding as which of the following types of drainage

Purulent

A nurse is preparing to insert an NG tube for a client who requires eneteral feedings. Which of the following instructions should the nurse give the client before beginning the procedure

Raise your index finger if you need to pause during the insertion

A nurse is caring for a client who is recieving fluid infusion through a peripheral Iv catheter. The nurse notes that the area of the arm immediately surrounding the insertion site is red and feels warm. WHich of the following actions should the nurse take?

Remove the IV Cath

A nurse is caring for a client who requires wrist restraints. Which of the following actions should the nurse take?

Remove the restraints at least every 2 hr

A nurse is screening a client who has an S shaped spinal column.

Scoliosis

A nurse is preparing to administer an intramuscular injection to a client who is overweight. Which of the following sites shoudl the nurse select for the injection?

Side hip between the iliac crest and anterior iliac spine

A nurse is caring for a client who is dehydrated. The nurse should expect that insensible fluid loss of approximately 500 to 600mL each day through which of the following organs>??

Skin

A nurse is reviewing the laboratory data of a client who has a fever and watery diarrhea. WHich of the following results should the nurse report to the provider?

Sodium 150 mEq/L

As part of a neurological examination, a nurse instructs a client to keep his eyes closed, places an object in his hand, and asks him to identify the object. Which of the following abilities is the nurse evaluating with this technique?

Stereognosis

A nurse is measuring a clients vital signs. The clients heart rate is 105/min. The nurse should document this finding as which of the following alterations

Tachycardia

An adolescent client in an outpatient mental health facility tells the nurse that he struggles to follow his treatment plans because his friends discourage him. Which of the following statements should the nurse make?

Tell me more about how your friends discourage you

A nurse is providing nutritional teaching to a group fo clients. Which of the following definitions for the recommended dietary allowance should the nurse include in the teaching

The RDA defines the level of nutrient intake that meets the needs of healthy people in various groups

A nurse is preparing to administer an afternoon dose of ampicillin to a client. The client appears upset and refuses to take the medication before throwing it on the floor. Which entries should the nurse record?

The client threw the medication on the floor

A nurse is teaching (AP) about proper hand hygiene. WHich of the following statements by the AP indicates an understanding of the teaching?

There are times I should use soap and water rather than alcohol based rub to clean my hands

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

Tie the restraint with a quick release knot

A nurse is preparing to assist an older adult client with ambulation following bed rest for 3 days. Which of the following actions should the nurse take to decrease the risk of a fall?

Use a gait belt during ambulation

A nurse is caring for a client who reports using several herbal medicines. WHich of the follwoing actions should the nurse take?

Verify that the herbal sup do not interact with med the provider has prescribed

A nurse is planning care for a client who has a wound infection following abdominal surgery. To promote healing and fight infection, which of the following vitamins and minerals should the nurse plan to increase the clients diet

Vitamin C and zinc

A nurse is caring for a client who has MRSA. WHICH OF THE FOLLWOING PRECAUTIONS SHOULD THE NURSE IMPLEMTENT?

Wear a gown when the client is in the room

A client is being discharged home with oxygen therapy delivered through a nasal cannula. WHich of the following instructions should the nurse provide to the client and family member?

Wear cotton clothing

A nurse is planning an in service training session about nutrition. WHich of the following statements should the nurse include in the teaching

fats provide energy

A nurse is performing an abdominal assessment of a client. WHich of the following positions should the nurse tell the client for this examination

supine

A nurse is teaching a client how to use and albuterol metered dose inhaler. Amfter removing and shaking, what is the next step?

-Hold mouthpiece 1-2 inches in front of your mouth -Tilt your head back and open mouth wide -Depress the canister while taking a slow deep breath -Hold breath for 10 seconds

A nurse is assessing a clients vascular system. Which of the following techniques should the nurse when evaluating the the carotid arteries

Auscultation of the arteries for bruits with the bell of the stethoscope

During the completion of a health history with a nurse the client reports intermittent chest pain for the past week. Which of the follwoing questions is the nurses priority?

Can you tell me what the pain felt like and show me exactly where it was?

A nurse is inserting an IV catheter for a client that results in a blood spill on her gloved hand. The client has no documented bloodstream infection. Which of the following actions should the nurse take?

Carefully remove the gloves and proceed with hand hygiene

A nurse is planning care for a client who has a prescription for collection of a sputum specimen for culture and sensitivity. Which of the following actions should the nurse take when obtaining the specimen?

Collect the specimen when the client rises in the morning

A nurse delegates the collection of a clients temperature to AP. The nurse in the documentation that the AP obtained the clients axillary temperature. However, the nurse wanted an oral temperature. The nurse should identify that which of the following rights of delegation should have prevented this situation from occurring

Right communication

A nurse is performing a neurological assessment for a client. Which of the following examinations should the nurse use to check the clients balance?

Romberg test

A nurse is caring for a client who is in the terminal stage of cancer. WHich of the following actions should the nurse take when she observes the client crying

SIt and hold the clients hand

A nurse is assessing a clients incision and observes the drainage to be blood tinged. Which of the following terms should the nurse use to document this finding

Sanguineous

A community health nurse is preparing a campaign about seasonal influenza. WHich of the following plans should the nurse include as a form of secondary prevention

Screening groups of older adults in nursing care facilities for early influenza manifestations

A nurse is preparing to administer an afternoon dose of ampicillin to.a client. The client appears upset and refuses to take the medication before throwing the pill on the floor.

The client threw the pill on the floor

A hospice nurse is visiting with the family member of a client. The family member states that the client has insomnia almost nightly. WHich of the follwoing practices should the nurse identify as contributing to the clients insomnia

The client watches tv in her bed during the day

A nurse is caring for an adult client who is grieving following the death of a loved one. Which of the following factors increases the client's risk of developing complicated grief?

The death was sudden

A nurse is developing a plan of care for a client. Which of the following pieces of information should the nurse consider when planning care that is culturally congruent?

The meaning of disease can vary widely across cultures

A nurse on a med surg unit is washing her hands prior to assissting with a surgical procedure. WHich of the following actions by the nurse demonstrates proper surg handwashing technique

The nurse holds her hands higher than her elbows while washing

A nurse is caring for a client who has a C-diff infection and is in contact isolation. Which of the following actions should the nurse take?

Wear gloves when changing clients gown

A nurse is performing a straight cauterization for a female client who has urinary retention. Which of the following actions indicates the nurse is using sterile technique?

Wiping the labia minora in an anteroposterior direction

A nurse is obtaining a capillary blood sample to determine a clients blood glucose level. The nurse prepares and punctures the clients finger for the procedure but does not obtain an adequate amount of blood. Which of the following actions should the nurse take next?

Wrap the clients finger in a warm washcloth

A nurse is teaching a client who is using a patient-controlled PCA pump to deliver morphine for pain management. WHich of the following statements should the nurse identify that the nurse understands the instructions?

I can still use my transcutaneuos electrical nerve stimulation unit while im pushing the PCA button

A nurse is teaching a client who has low back pain about heat therapy. Which of the following statements by the client indicates an understanding of the teaching?

I need to place a towel between the heating pad and skin to reduce the risk of burns

A nurse ina provider's office is talking with an older adult client who reports having trouble sleeping. Which of the following statements should the nurse identify as possible cause of the client's sleep difficulties?

I often have a cup of coffee before going to bed

A nurse is caring for a client who is recieving mechanical ventilation via a tracheostomy tube and has a gastronomy tube for enteral feedings. WHich pieces of information are critical to communicate to the next nurse who will be caring for this client

-New prescriptions -ABG results Tracheal secretion characteristics

A nurse is an emergency department is caring for a client who reports developing severe right eye pain with a gritty sensation while sawing wood. Which of the following actions should the nurse take first?

Ask the client about first aid performed at the scene

A nurse is performing an admission for a client who has asthma and reports several food allergies. Which of the following actions should the nurse take first?

Ask the client to identify the specific food allergies

A nurse is caring for a client who is scheduled to receive transcutaneous electrical nerve stimulation for pain management. The client asks how a TENS unit helps relieve pain?

It modulates the transmission of the pain impulse

A nurse in a long term facility is admitting a client who is incontinent and smells strongly of urine. His partner who has been caring for him at home, is embarassed and apoloigizes for the smell. Which os the following responses should the nurse make?

It must be difficult to care for someone who is confined to bed

A nurse is cleaning a clients wound by swabbing from the area of least contamination to an area of greater contamination. WHich of the following rationales hsould the nursy identify for using this technique?

Keeping microorganisms from entering the wound

A nurse is supervising a newly licensed who is administering a controlled substance. Which of the following action by the newly licensed nurse indicates an understanding of the procedure

Asking another nurse to observe the disposal of an unused portion of the medication

A nurse is using I-SBAR communication tool to give a clients provider information about the client. The nurse should convey this clients pain status in which of the report?

Assessment

A nurse is caring for a client who has emphysema. The client has not stopped smoking cigarettes and states, " Its too late for me to quit" WHich of the following action should the nurse take?

Assist the client in finding local smoking cessation assistance programs

A nurse is beginning a therapeutic relationship with a client. WHich of the following actions should the nurse take to convey empathy when using the therapeutic comminication technique of active listening

Assume an open position

A nurse is planning weight loss strategies for a group of clients who are obese. Which of the following actions by the nurse will improve the clients commitment to the clients long term goal of weight loss

Attempt to increase the clients self motivation

A nurse is assessing a client who is undergoing a physical examination. Following the inspection which of the following techniques should the nurse use when assessing the clients abdomen

Auscultation

A nurse is caring for a client who requires ventilatory assistance with breathing following a motor vehicle crash. The nurse should suspect an injury to which of the following parts of the brain?

Brainstem

A nurse is preparing a client for discharge and providing instructions about performing dressing changes at home. WHich of the following statements should the nurse identify as an indication that the client understands medical asepsis

Ill wash my hands before I remove the old dressing and again before putting on the new one

A nurse is caring for a client who is 48 hr postop following a small bowel resection. The client reports gas pains in the periumbilical area. The nurse should plan care based on which of the following factors contributing to this postop complication

Impaired peristalsis of the intestines