Fundamentals

A nurse is caring for a client who is postoperative following a vaginal hysterectomy and asks for a drink. Her postoperative diet prescription states "clear liquids; advance diet as tolerated." Which of the following responses should the nurse make?

"I am going to listen to your abdomen"

A nurse is instructing a client about collecting a 24-hr urine specimen for creatinine clearance. Which of the following statements should the nurse identify as an indication that the client understands the procedure?

"I'll make sure to keep the collection bottle in the container of ice they gave me."

A nurse is caring for a client who is scheduled to receive transcutaneous electrical nerve stimulation (TENS) for pain management. The client asks the nurse how a TENS unit helps to relieve pain. Which of the following responses should the nurse make?

"It modulates the transmission of the pain impulse."

A nurse is talking with the parent of a preschool-aged child who tells the nurse, "My child has suddenly become disinterested in certain foods." Which of the following statements should the nurse make?

"Keep a diary of the foods your child eats each day."

A nurse is providing teaching to an older adult client who has constipation. Which of the following statements should the nurse include in the teaching?

"Sit on the toilet 30 minutes after eating a meal."

A nurse is assessing a client's nutritional status. The nurse determines the client is consuming 500 calories more per day than his energy fevel requires. If his dietary habits do not change, how long will it take the client to gain 4.5 kg (10 |b)?

10 weeks

A nurse is measuring the blood pressure of several clients. Which of the following results is within the expected reference range for blood pressure?

116/70 mmHg

A nurse is caring for a client who is receiving dextrose 5% in water IV at 150 mL/hr and has ingested 4 oz of water and ½ pint of milk. What is the total 8-hr fluid intake in milliliters that the nurse should document for this client? (Round the answer to the nearest whole number and fill in the blank with the numeric value only.)

1560 Follow these steps for the conversions of oz to mL: Step 1: What is the unit of measurement the nurse should calculate? mL Step 2: Set up an equation and solve for X. 1 oz / 30 mL = 4 oz / X mL X = 120 Step 3: Round if necessary. Step 4: Determine whether the conversion to mL makes sense. If 1 oz = 30 mL, it makes sense that 4 oz = 120 mL. Follow these steps for the conversions of pints to mL: Step 1: What is the unit of measurement the nurse should calculate? mL Step 2: Set up an equation and solve for X. 1 pint / 480 mL = 0.5 pint / X mL X = 240 Step 3: Round if necessary. Step 4: Determine whether the conversion to mL makes sense. If 1 pint = 480 mL, then 1/2 pint = 240 mL. For the total intake, calculate 150 mL x 8 hr = 1200 mL + 120 mL + 240 mL = 1560 mL

A nurse is caring for a client who requires fluid restriction and may drink only 1 oz of water with each oral medication. How many milliliters of water should the nurse document as intake for the 3 separate medications the client receives during a 12-hr night shift? (Round the answer to the nearest whole number and fill in the blank with the numeric value only.)

90 (Follow these steps for the conversions of oz to mL: Step 1: What is the unit of measurement the nurse should calculate? mL Step 2: Set up an equation and solve for X. 1 oz/30 mL = 3 x 1 oz/X mL 1 oz/30 mL = 3 oz/X mL X = 90 Step 3: Round if necessary. Step 4: Determine whether the conversion to mL makes sense. If 1 oz = 30 mL, then 3 oz = 90 mL.)

A nurse on an oncology unit receives report at the beginning of her shift about 4 clients who are postoperative. Which of the following clients should the nurse see first?

A client who is 2 days postoperative following a colectomy due to colorectal cancer and has an ostomy bag full of bright red, bloody drainage

A nurse is changing the dressings for a client recovering from an appendectomy following a ruptured appendix. The client's surgical wound is healing by secondary intention. Which of the following observations should the nurse report to the provider?

A halo of erythema on the surrounding skin

A nurse is supervising a newly licensed nurse who is administering a controlled substance. Which of the following actions 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 in a provider's office is teaching a client about foods that are high in fiber. Which of the following food choices made by the client indicate an understanding of the teaching? (Select all that apply.)

Black beans Whole-grain bread

A nurse is caring for a client who requires a peripheral IV insertion. When choosing the site, which of the following sites should the nurse select?

Choose a vein that is soft on palpation

A nurse is collecting a urine specimen for culture and sensitivity for a client who has a urinary tract infection. The client has an indwelling urinary catheter in place. Which of the following actions should the nurse take?

Clamp the tubing below the collection port

A nurse is preparing to assess the function of the client's trigeminal nerve (cranial nerve V). Which of the following items should the nurse gather for the test?

Cotton wisps

A nurse is caring for a client who has acute renal failure. Which of the following assessments provides the most accurate measure of the client's fluid status?

Daily weight

A nurse is caring for a client who has a BMI of 29 and expresses a desire to lose weight. Which of the following actions should the nurse take first?

Determine the client's intention to change current eating habits

A nurse is providing preoperative teaching to a client who is scheduled for arthroplasty in the next month and may require a blood transfusion. The client expresses concern about the risk of acquiring an infection from the blood transfusion. Which of the following statements should the nurse share with the client?

Donate autologous blood before the surgery

A nurse is assessing a client. Which of the following findings should the nurse identify as an indication of protein-calorie malnourishment? (Select all that apply.)

Dry, brittle hair Edema Poor wound healing

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 prevention?

Educating clients about the recommended immunization schedule for adults

A nurse is applying an ice bag to the ankle of a client following a sports injury. Which of the following actions should the nurse take?

Fill the bag 2/3 full with ice

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

Gait

A nurse in an urgent-care center is caring for a 15-year-old client whose symptoms suggest a sexually transmitted infection (STI). The client's parent is unavailable, but the client's grandmother accompanied the client to the clinic. Which of the following actions should the nurse take?

Have the adolescent sign the consent form

A nurse is teaching a client about lifestyle changes to manage a chronic illness. Which of the following strategies should the nurse use first to help the client make a commitment to these lifestyle changes?

Help the client identify ways that these changes will result in positive personal outcomes

A nurse is caring for a client who has a tracheostomy and requires suctioning. Which of the following actions should the nurse take?

Hyperoxygenate the client before suctioning

A nurse is caring for a client who requires a chest X-ray. Prior to the client being transported for the procedure, which of the following actions should the nurse take first?

Identify the client using two identifiers

A nurse is administering a cleansing enema to a client who is scheduled for a diagnostic procedure. Which of the following actions should the nurse take?

Insert the tip of the tubing 8 cm (3.1 in)

A nurse in the emergency department is caring for an inmate who has a laceration and is bleeding. The client was brought to the facility by a guard who asks the nurse about the client's HIV infection status. Which of the following actions should the nurse take?

Instruct the guard to ask the inmate

A nurse is caring for a client who has a temperature of 38.7°C (101.7°F). Which of the following actions should the nurse take?

Keep the client's bed linens dry

A charge nurse is observing a newly licensed nurse perform tracheostomy care for a client. Which of the following actions by the newly licensed nurse requires intervention?

Obtaining cotton balls for the tracheostomy care.

A nurse is planning to document care provided for a client. Which of the following abbreviations should the nurse use?

PC for after meals

A nurse is obtaining the blood pressure in a client's lower extremity. Which of the following actions should the nurse take?

Place the bladder of the cuff over the posterior aspect of the thigh

A nurse is providing oral care for a client who is unconscious. Which of the following actions should the nurse take?

Place the client in a lateral position with the head turned to the side before beginning the procedure.

A nurse is planning to collect a stool specimen for ova and parasites from a client who has diarrhea. Which of the following actions should the nurse take when collecting the specimen?

Place the stool specimen collection container in a biohazard bag.

A nurse is inserting an NG tube into a client who begins to cough and gag. Which of the following actions should the nurse take?

Pull the NG tube back slightly

A nurse is helping a client change his hospital gown. The client has an IV infusion via an infusion pump. Which of the following actions should the nurse take first?

Remove the sleeve of the gown from the arm without the IV line

A nurse is preparing to administer a unit of packed RBCs to a client when she discovers that the IV line is no longer patent. The IV team informs her that someone can come to initiate a new line in 30 min. Which of the following actions should the nurse take?

Return the blood to the laboratory

A nurse delegates the collection of a client's temperature to an assistive personnel (AP). The nurse notes in the documentation that the AP obtained the client's 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 caring for a client who has a history of dysrhythmias. Upon entering the room, the nurse discovers the client is unresponsive to verbal or painful stimuli, has no respirations, and is pulseless. Which of the following actions should the nurse take first?

Start chest compressions

A nurse is caring for an adult client in the terminal stages of lung cancer who refuses any further treatment. The nurse should provide care that facilitates which of the following outcomes?

Supports self-determination

A nurse is evaluating a client's use of crutches. The nurse should identify that which of the following actions by the client indicates safe usage of this equipment?

The client has slightly flexed elbows when ambulating with the crutches

A nurse is assisting a client who has right-sided weakness while ambulating using a cane. Which of the following client actions should indicate to the nurse that the client understands the procedure of cane walking?

The client keeps 2 points of support on the ground

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. Which of the following entries should the nurse enter into the client's medical record?

The client threw the medication 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 following practices should the nurse identify as contributing to the client's insomnia?

The client watches television in her bed during the day

A nurse is preparing to administer a unit of packed RBCs to a client. Which of the following pieces of information must the nurse verify with another nurse prior to the administration? (Select all that apply.)

The client's ID number, the client's name, ABO compatibility, Rh compatibility

A nurse is providing nutrition counseling to a middle-aged adult client who has a sedentary job. Which of the following factors should the nurse consider?

The client's basal metabolic rate could decrease

A nurse on a medical-surgical unit is washing her hands prior to assisting with a surgical procedure. Which of the following actions by the nurse demonstrates proper surgical handwashing technique?

The nurse holds her hands higher than her elbows while washing

A nurse is caring for a client who had a spinal cord injury and has paraplegia. Client is repositioned every 2 hr. Passive range of motion exercises to lower extremities performed 3 times per day. Left calf circumference is 40.1cm Right calf circumference is 40 cm Feet are cool to touch, color pale, with bilateral pedal pulses 1+. Foot drop is noted bilaterally, foot boot applied as prescribed.

The nurse should first address the client's oxygen saturation followed by the client's temperature

A nurse is witnessing a client sign an informed consent form for surgery. What is the nurse affirming by this action?

The signature on the preoperative consent form is the client's

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 planning to administer pain medication to a client following abdominal surgery. Which of the following actions should the nurse take first?

Use the pain scale to determine the client's pain level

A nurse rates a client's biceps reflex as a 2+. Which of the following characteristics should the nurse document about the client's reflexes?

average

A nurse is performing a focused assessment of a client's peripheral vascular system. In which of the following locations should the nurse palpate the posterior tibial pulse?

below medial malleolus

A nurse is reviewing a client's 24 hr dietary recall. The client reports eating a slice of toasted white bread with butter, a banana, a glass of milk, and a cup of coffee for breakfast; grilled chicken, a baked potato, and a glass of milk for lunch; an apple and cheddar cheese for a snack; and 2 servings of chicken, 2 cups of steamed broccoli, and a glass of milk for dinner. This client's diet is deficient in which of the following food groups?

grains

A nurse is caring for a client who has a gastric ulcer. The nurse should explain that prolonged exposure of the body to stress can also cause which of the following to occur?

hyperglycemia

A nurse is teaching a group of unit nurses about the experiences of clients who are having surgery. In which phase of care is the client transferred to the surgical suite table before being transferred to the PACU?

intraoperative

A nurse is providing teaching about crutches to a client who has a fracture of the right foot. Which of the following instructions should the nurse include?

keep the rubber crutch tips securely in place

A nurse is removing personal protective equipment (PPE) after performing a procedure for a client who requires isolation precautions. Which of the following items of PPE should the nurse remove first?

mask

A nurse is performing a physical examination for a client. To evaluate the client's skin moisture, the nurse should use which of the following techniques?

palpation

A nurse has received a prescription for dextran to administer to a client. The nurse should recognize that dextran belongs in which of the following functional classifications?

plasma volume expanders

A home health nurse is visiting an older adult client with severe dementia. The client's son, who serves as her primary caregiver, reports being "exhausted" from working part-time and caring for his mother at home. Which of the following options should the nurse suggest to the caregiver?

respite care

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

side hip between the iliac crest and anterior iliac spine

A nurse is planning to obtain the vital signs of a 2-year-old child who is experiencing diarrhea and may have a right ear infection. Which of the following routes should the nurse use to obtain the child's temperature?

temporal