Fundamentals

A nurse is contributing to the plan of care for a client who is dying. Which of the following interventions should the nurse recommend to include the clients family in the plan of care? (Select all that apply) -Share the clients status with the family daily -Suggest that a family members return home at night to allow the client to get some rest -Encourage the family to comb the clients hair -Urge the family to help the client fill out the food menu -Ask the family to encourage the client to eat

-Share client status with the family -Encourage family to comb clients hair -Urge family to help fill out food menu

A nurse is administering pilocarpine eye drops to a client who has glaucoma. Which of the following actions should the nurse take? 1) Apply gentle pressure to the lacrimal sac for 30-60 seconds following administration 2) Administer the medication onto the cornea 3) Instruct the client to look downward while the medication is being administered 4) While the medication is being administered, hold the dropper 4 cm above the eye

1) Apply gentle pressure to the lacrimal sac for 30-60 seconds following administration

A nurse is performing a guaiac smear on a clients stool specimen. Which of the following test results should the nurse recognize as indicating a positive finding? 1) Blue 2) Pink 3) Yellow 4) Green

1) Blue

A nurse is reinforcing teaching about measures to promote sleep with an older adult client who has rheumatoid arthritis. Which of the following instructions should the nurse include? 1) Decrease intake of fluids 2 hr prior to bedtime 2) Take a 60 min nap everyday 3) Avoid taking an analgesic 30 min prior to bedtime 4) Walk briskly 1 hr before bedtime

1) Decrease intake of fluids 2 hr prior to bedtime

A nurse is reinforcing discharge teaching with a client, following a sigmoidoscopy. Which of the following statements by the client indicates a need for intervention? 1) I should change my appliance daily 2) I should expect minimal bleeding when I touch the site 3) My stoma should be bright pink or red 4) My stools should be solid and formed

1) I should change my appliance daily

A nurse is caring for a client who is receiving medication to control anxiety. Which of the following findings indicates that the client is experiencing mild anxiety? 1) Insomnia 2) Nausea 3) Dizziness 4) Facial twitching

1) Insomnia

A nurse is caring for a client who is receiving intermittent enteral feedings. Which of the following is the priority action for the nurse to take? 1) Measure the clients gastric residual before each feeding 2) Change the bag and tubing every 24 hr 3) Monitor intake and output 4) Flush the tubing with 30 mL of water after each feeding

1) Measure the clients gastric residual before each feeding

A nurse is collecting data from a middle adult client for a safety evaluation. Which of the following is the priority safety risk for clients at this age? 1) Motor-vehicle crash 2) Fall-related injuries 3) Carbon monoxide poisoning 4) Gunshot wounds

1) Motor-vehicle crash

A nurse receiving change of shift report from another nurse and notes the smell of alcohol on the nurses breath. Which of the following actions should the nurse take? 1) Notify the charge nurse 2) Ask another co worker about the nurses performance 3) Remove the nurse from the unit 4) Arrange transportation for the nurse

1) Notify the charge nurse

A nurse is reinforcing teaching with a newly licensed nurse who is setting up a sterile field. Which of the following actions by the newly licensed nurse indicates a need for further teaching? 1) Opening the first flap of a sterile package toward her 2) Dropping sterile gauze onto the field from a height of 15 cm 3) Removing and inverting a lid, before placing it onto a non sterile surface 4) using sterile forceps to arrange items on the field

1) Opening the first flap of a sterile package toward her

A nurse is caring for a client who has expressive aphasia. Which of the following methods should the nurse plan to use to communicate with the client? 1) Picture board 2) Sign language 3) Laptop computer 4) Paper and pencil

1) Picture board

Med surg fire

1) Remove clients 2) Pull alarm 3) Conain 4) Extinguish flame

A nurse is preparing a client for a romberg test. Which of the following statements is appropriate for the nurse to make to this client at this time? 1) Stand with your feet together and your arms at your sides 2) After I place the tuning fork, tell me when you no longer hear the sound 3) Im going to stoke the lateral side of the bottom of your foot 4) Touch each fingertip as quickly as possible with your thumb

1) Stand with your feet together and your arms at your sides

A nurse is providing care to a client who has a new colostomy. Which of the following findings should the nurse report to the provider? 1) The skin surrounding the stoma is red 2) The stoma has a moderate amount of swelling 3) There is a build up of adhesive residue surrounding the stoma 4) The client is having a large amount of liquid stool

1) The skin surrounding the stoma is red

Steps for catheter

1) Verify prescription 2) Provide privacy 3) Position and drape 4) Open sterile package

A nurse is contributing to the plan of care for four clients. For which of the following clients should the nurse initiate airborne precautions? 1) A client who has pneumonia 2) A client who has measles 3) A client who has pertussis 4) A client who has MRSA

2) A client who has measles

A nurse is assisting with the admission of a client who has active TB. Which of the following actions should the nurse plan to take? 1) Restrict the clients visitors to the immediate family 2) Assign the client to a negative pressure room 3) Discard personal protective equipment outside the clients room 4) Have the client wear a HEPA mask when being transported through the facility

2) Assign the client to a negative pressure room

A nurse is caring for a client who has a prescription for a potassium supplement. The client tells the nurse that the pill is too large to swallow and refuses to take it. The nurse offers to break the pill into 2 smaller pieces. The nurse is demonstrating which of the following ethical principles? 1) Autonomy 2) Beneficence 3) Justice 4) Nonmaleficence

2) Beneficence

A nurse is caring for a client who is scheduled for a total hip arthroplasty the next morning. The nurse questions the client regarding the consent for surgery. The client states, "I don't know what you are talking about. No one has spoken to me about the surgery." The nurse should 1) Explain the procedure to the client 2) Call the clients surgeon to explain the procedure 3) Contact the clients partner to explain the procedure 4) Ask the charge nurse to explain the procedure to the client

2) Call the clients surgeon to explain the procedure

A nurse is contributing to the plan of care for a client who has a prescription for elastic bandages to the lower extremities. Which of the following actions should the nurse recommend for the plan of care? 1) Check for cap refill proximally to the elastic bandages every 12 hr 2) Compare the clients pedal pulses bilaterally every 4 hr 3) Place the client legs in a dependent position for 30 min before applying the elastic bandages 4) Remove the elastic bandages every other day to inspect the skin

2) Compare the clients pedal pulses bilaterally every 4 hr

A nurse is caring for a client who is postoperative following radical mastectomy. Therapeutic interventions for helping the client accept her altered body image include: 1) Changing the subject to more positive topics 2) Encouraging her to assist in dressing changes 3) Reassuring her that she is still attractive 4) Requesting a mental health referral from her provider

2) Encouraging her to assist in dressing changes

A nurse is assisting with the care of a client who has a prescription for IV therapy. The client tells the nurse that he has numerous allergies. Which of the following allergies should the nurse bring to the attention of the charge nurse prior to the initiation of the therapy? 1) Eggs 2) Latex 3) Seafood 4) Bee stings

2) Latex

A nurse is caring for a client who has C. Diff. Which of the following solutions should the nurse use to perform hand hygiene while caring for this client? 1) Isopropyl alcohol 2) Mild soap 3) Chlorhexidine 4) Triclosan

2) Mild soap

A nurse is caring for a client who has a new prescription for a chest restraint. Which of the following actions is appropriate for the nurse to include in the plan of care? 1) Check that the chest restraint is tied to a fixed frame of the bed 2) Observe the clients chest movement with inspiration and expiration 3) Remove the chest restraint every 4 hr to allow movement 4) Tie the chest restraint with a knot that will tighten when pulled

2) Observe the clients chest movement with inspiration and expiration

A nurse is assisting a provider with an abdominal paracentesis for a client who has ascites. Which of the following is an appropriate action for the nurse to take? 1) Encourage the client to drink plenty of fluids prior to the procedure 2) Positions the client in a sitting position for the procedure 3) Measure the clients girth at the level of the sternum after the procedure 4) Encourage the client to raise his hand if he experiences discomfort during the procedure

2) Positions the client in a sitting position for the procedure

A nurse is assisting with discharge planning for an older adult client. According to mallows hierarchy of needs, which of the following interventions is the priority? 1) Encourage the client to volunteer at the local food pantry 2) Promote the clients involvement at the local senior center 3) Support the client in finding and enjoyable hobby 4) Suggest the client find ways to support environmental conservation

2) Promote the clients involvement at the local senior center

A nurse is contributing to the plan of care for a client who has at risk for developing foot drop due to multiple sclerosis. Which of the following actions should the nurse recommend to include in the plan of care? 1) Flex the client feet using pillows 2) Support the client feet with foot boots 3) Place a hand roll under the clients heels 4) Remove ankle foot orthotic devices every 4 hr

2) Support the client feet with foot boots

A nurse is observing an AP who is obtaining a urine specimen from a client for a culture and sensitivity test. Which of the following actions by the AP is appropriate? 1) AP uses one antiseptic towelette, folding it over with each swipe 2) The AP passes the specimen container into the urine stream after the client has begun urinating 3) The AP collects the urine specimen after antibiotic administration 4) The AP securely applies the specimen label to the lid of the container

2) The AP passes the specimen container into the urine stream after the client has begun urinating

A nurse is collecting data from a client who has cognitive impairment and is 6 hr postop. The client is unable to respond to the nurses questions about pain level. Which of the following findings should indicated to the nurse that the client is experiencing pain? 1) The clients BP decreases 2) The client assumes a fetal position 3) The client is shivering 4) The clients pulse is thready

2) The client assumes a fetal position

A nurse is observing a client who is learning to walk with crutches. Which of the following observations made by the nurse demonstrates that the client understand proper use of the crutches? 1) When standing, the client bends forward at a 15 degree angle at the waist 2) The top of each crutch is three to four finger widths below the axilla 3) Elbows are straight when the client stands 4) When using a three point gait the client bears equal weight on both feet

2) The top of each crutch is three to four finger widths below the axilla

A nurse is reinforcing teaching with the partner of a client who is immobile. Which of the following instructions should the nurse give the partner about turning the client in bed? 1) Keep your feet close together 2) Tighten you stomach muscles 3) Straighten you knees 4)Bend at your waist

2) Tighten your stomach muscles

A nurse is weighing a client who has heart failure and notes that the client has gained 1.5 kg in the past 24 hr. The nurse should calculate that the client has retained how much fluid? 1) 500 mL 2) 1,000 mL 3) 1,500 mL 4) 2,000 mL

3) 1,500 mL

While monitoring a client for edema of the lower extremities, which of the following actions should the nurse take? 1) Palpate for dorsalis pedis pulse 2) Pinch and pull up the skin gently at the top of the foot 3) Apply pressure to the skin at the clients ankle 4) Press on the nail bed of the clients big toe

3) Apply pressure to the skin at the clients ankle

A nurse is collecting data from a client. The nurse should recognize that which of the following findings is an indicator of pain? 1) Decreased respiratory rate 2) Lethargy 3) Dilated pupils 4) Bradycardia

3) Dilated pupils

A nurse is reinforcing teaching with a client who has a new hearing aid. Which of the following client statements indicates an understanding of the teaching? 1) I will wear my hearing aid for 2 hours a day for the first 3 days 2) I will leave the battery in place when I am not using the hearing aid 3) I will avoid using hairspray while I have my hearing aid in 4) I will leave my hearing aid in when I am showering

3) I will avoid using hairspray while I have my hearing aid in

A nurse is collecting data from a client who is experiencing pain. Which of the following client statements describes the quality of the clients pain? 1) My pain level is 6/10 2) I become sick to my stomach when my pain is at its worst 3) My pain is sharp and stabbing 4) My pain is relieved when I use a heating pad

3) My pain is sharp and stabbing

A nurse is preparing to take a client BP. Which of the following actions demonstrates proper technique? 1) Inflate cuff to 10 mm Hg above the palpated systolic pressure to obtain an accurate reading 2) Elevate the clients arm the shoulder level 3) Release the cuff pressure at 2-3 mm Hg per second 4) Turn the clients arm so his palm faces down

3) Release the cuff pressure at 2-3 mm Hg per second

A client who had a recent below the knee amputation says, "I don't know how I can continue to live my life without my leg." Which of the following is the appropriate response by the nurse? 1) You can have a prosthesis after your recovery has progressed 2) I am so sorry. I know I would hate to lose my leg 3) Tell me what concerns you have about your future 4) Your focus right now should be on recovering from the surgery

3) Tell me what concerns you have about your future

A nurse is preparing to transfer a client from the hospital to a long term care facility. Which of the following strategies will promote continuity of care? 1) The social worker instructs the clients partner to provide info about the clients medical status 2) The unit secretary requests the clients transfer to the long term care facility 3) The nurse communicates with personnel at the long term care facility regarding the clients medical status 4) The provider supplies a copy of the clients medical record to the long term care facility

3) The nurse communicates with personnel at the long term care facility regarding the clients medical status

A nurse is documenting information for a client following the insertion of and indwelling urinary catheter. Which of the following is an accurate documentation made by the nurse? 1) Client reported some pain during procedure 2) The client seemed disagreeable during the procedure 3) Urine is clear amber in color 4) Immediate return of large volume of urine

3) Urine is clear amber in color

A nurse is caring for a young adult client who has recently undergone a total bilateral mastectomy. Which of the following statements by the client requires immediate action by the nurse? 1) I don't understand why everyone is so worried about me 2) I don't know if ill ever find someone who wants to marry me 3) When I look at myself in the mirror, I don't know if I can go on 4) I feel like the doctor pressure me into having the mastectomy

3) When I look at myself in the mirror, I don't know if I can go on

A nurse is caring for a client who has a terminal illness. Which of the following responses by the nurse is therapeutic? 1) Are you ready to talk about your diagnosis? 2) I heard your provider gave you some difficult news. I feel so sorry for you 3) Would you like me to sit quietly with you for a while? 4) I understand that it will be very difficult for you to face your current situation

3) Would you like me to sit quietly with you for a while?

A nurse is caring for four clients. For which of the following clients should the nurse employ the therapeutic communication technique of silence? 1) A client who plans to leave the hospital against medical advice 2) A client who informs the nurse that he has made his funeral arrangements 3) A client who tells the nurse that the night shift nurse did not bring his medication 4) A client who has just experienced the death of his child

4) A client who has just experienced the death of his child

A nurse is reinforcing dietary teaching with a client who has chronic kidney disease. Which of the following food choices demonstrates that the client understands the teaching? 1) Cantaloupe 2) Baked potato 3) Banana 4) Applesauce

4) Applesauce

A nurse is caring for a client who is prescribed a high protein diet to promote wound healing after surgery. The clients religion prohibits eating meat on particular days. Which of the following is an appropriate action for the nurse to take? 1) Encourage the client to eat meat during this time to promote healing 2) Advise the client to eat everything on the tray except the meat 3) Request that the family bring in food for the client 4) Ask the dietitian to recommend alternative food choices for the client

4) Ask the dietitian to recommend alternative food choices for the client

A nurse is caring for an older adult client and is concerned that the client may have a fecal impaction. Which of the following is the most important question for the nurse to ask? 1) What types of foods have you been eating? 2) Are you using stool softeners or laxatives? 3) Have you been passing gas? 4) Have you had small, liquid stools?

4) Have you had small, liquid stools?

A nurse is preparing to administer a rectal suppository to a client. Which of the following actions should the nurse take? 1) Instruct the client to hold his breath while inserting the suppository 2) Place the suppository before the internal sphincter 3) Position the client on his right side 4) Insert the suppository against the rectal mucosa

4) Insert the suppository against the rectal mucosa

A nurse is repositioning a client who is quadriplegic and in the supine position. Which of the following are appropriate nursing actions to prevent client musculoskeletal injury? 1) Support the client head with a pillow that maintains cervical flexion 2) Position the clients shoulders off the pillow for internal rotation 3) Place the clients arms at his sides to keep his elbows extended 4) Internally rotate the client hips by using a trochanter roll

4) Internally rotate the client hips by using a trochanter roll

A nurse is caring for a client who has heart failure and is having severe difficulty breathing. The nurse understands that which of the following oxygen delivery systems provides the highest concentration of oxygen? 1) Rebreather mask 2) Simple face mask 3) Venturi mask 4) Nonrebreather mask

4) Nonrebreather mask

A client who is scheduled for surgery tells the nurse that she does not understand the procedure and is having second thoughts. Which of the following actions should the nurse take? 1) Offer information about alternative therapies to the procedure 2) Contact a family member to convince the client to change his mind 3) Tell the client the benefits of the surgery 4) Notify the charge nurse of the clients concerns

4) Notify the charge nurse of the clients concerns

A nurse is providing palliative care for a client who is at the final stage of life. Which of the following is an appropriate action by the nurse? 1) Whisper when speaking to the family at the clients bedside 2) Apply oxygen when the client has periods of apnea 3) Administer IV fluids to control end of life discomfort 4) Provide opioid medications as needed to relieve the clients signs of pain

4) Provide opioid medications as needed to relieve the clients signs of pain

A nurse is caring for a client who must restrict fluids and reports feeling thirsty. Which of the following interventions should the nurse recognize as being appropriate? 1) Give half the fluid allowance during the day and half in the evening 2) Suggest eating regular hard candy or chewing gum 3) Offer cool snacks such as gelatin or custard frequently 4) Provide oral hygiene rinse frequently

4) Provide oral hygiene rinse frequently

A nurse is caring for a client who has a new diagnosis of cancer. Which of the following actions allows the nurse to provide care while maintaining the clients confidentiality? 1) Sharing the clients prognosis with a member of the clients family 2) Discussing the clients status with a member of pastoral care 3) Offering information to a friend of the client over the phone 4) Providing info to another nurse at change of shift

4) Providing info to another nurse at change of shift

A nurse is reinforcing teaching with an older adult client about oral hygiene. Which of the following instructions should the nurse include in the teaching? 1) Use firm bristled toothbrush 2) Use lemon glycerin sponges between meals for dry mouth 3) Replace toothbrush every 6 months 4) Replace toothbrush following an illness

4) Replace toothbrush following an illness

A nurse is contributing to the plan of care for a client who is terminally ill and has decided to discontinue aggressive therapy and only receive comfort care. Which of the following actions demonstrates nursing advocacy for the clients decision? 1) Notify the clients family of the request 2) Discuss the consequences of the request with the client 3) Inform the client about new advances in medical technology 4) Request a palliative care referral for the client

4) Request a palliative care referral for the client

A nurse is reinforcing teaching with an AP about caring for a client who is on contact precautions. Which of the following actions by the AP indicates an understanding of the teaching? 1) The AP places contaminated linens in a container outside the clients room 2) The AP holds infectious material close to his body 3) The AP disposes of his gown after exiting the clients room 4) The AP applies gloves over his gown sleeves

4) The AP applies gloves over his gown sleeves

A nurse is contributing to the plan of care for a client who is on droplet precautions. Which of the following interventions should the nurse recommend for the plan of care? 1) Placing the client in a negative pressure room 2) Wearing a gown while giving the client medication 3) Removing personal protective equipment immediately upon exiting the client room 4) Wearing a mask while taking the clients vital signs

4) Wearing a mask while taking the clients vital signs

A nurse is caring for a client who is obese. The nurse should recognize that the client is at risk for which of the following? (select all that apply) -Cholelithiasis -Osteoporosis -Type 2 diabetes mellitus -Hypertension -Graves' disease

Cholelithiasis, Type 2 diabetes, hypertension

Audio clip

Tell the nurses that this conversation is not appropriate