fundamentals exam #2

A nurse manager identifies a need for further instruction when a new nurse makes which statement?

"The client is always the best source for collecting data."

Which statement made by the nurse indicates data that would be documented as part of an objective assessment?

"The client's right leg is cold to the touch, from the knee to the foot."

The nurse is planning to do a physical assessment on a newly admitted client. The assessment will be a review of systems. This means the nurse plans to:

complete an exam of all body systems.

A client is admitted to a hospital unit with scleroderma. The nurse is unfamiliar with this condition. What is the nurse's best source of information about this condition?

consult nursing and medical literature

The nurse is preparing to administer a client's intramuscular injection and intends to use the technique shown. What potential benefit of this technique should the nurse describe?

decreased irritation and pain in subcutaneous tissue

A nurse is administering a hepatitis B immunization injection to an adult client. Which site would the nurse choose for this injection?

deltoid

A nurse is administering an adult client's ordered antipsychotic drug intramuscularly. What would be the most appropriate site for administration?

deltoid

Which component of a nursing diagnosis gives additional meaning to the nursing diagnosis?

descriptors

After teaching a group of nursing students about pharmacokinetics, the instructor determines that the education was successful when the students identify what process by which the medication is delivered to the target cells and tissues?

distribution

Which type of assessment would the nurse be expected to perform on the client who is 1 day postoperative following a cholecystectomy?

focused

A nurse needs to administer an intradermal injection to a client. What is the most common site for administering an intradermal injection?

forearm

What must the nurse do to identify actual or potential health problems?

gather data

A nurse educator is teaching a student nurse how to choose the correct needle for an injection. Which guidelines for needle selection might they discuss?

gauge gets bigger needle gets smaller

A pregnant client asks the nurse for information on breastfeeding. What type of nursing diagnosis should the nurse formulate?

health promotion

A nurse is asking questions about a client's sexual history. Which is the best question for the nurse to ask to determine the client's use of safer sexual practices?

how do you protect yourself during sex

The nurse has identified a nursing diagnosis of "Risk for Impaired Parenting" for a client who has recently learned of being pregnant. What assessment data would be appropriate to lead the nurse to select this diagnosis?

idk how to take care of a baby

The nurse is assessing a 3-week-old infant who has not gained weight since birth. The infant's bowel sounds are present in all quadrants and breath sounds are clear to auscultation. The infant's mother reports that the child cries much of the night but sleeps better in the daytime. The mother reports that the child only breastfeeds about four times in a 24-hour period and that the mother doesn't seem to have much milk. Which nursing diagnosis would be of highest priority for this client?

ineffective breastfeeding

During the introductory phase of interviewing a client for the purpose of obtaining information for the nursing history, the nurse should:

inform the client of the maintenance of confidentiality.

The nurse is comparing a client's current status to baseline data obtained upon admission to long-term care facility 6 months previously. Which tool should the nurse use to make this form of assessment?

time lapsed assessment

An older adult client who has been living in an assisted living facility for several months informs a visiting family member that a nurse is coming to do some kind of checkup. Which type of check would be most appropriate for the nurse to perform on this client?

time-lapsed assessment

The primary reason for the Controlled Substances Act is:

to prevent drug use and dependence.

When performing an assessment, the nurse should focus most on the developmental stage for which client?

toddler

Which traits of the nurse are most important for an assessment to be successful?

trustworthy and confident

The nurse is caring for an adolescent verbalizing a desire to seek counseling for grief related to the death of a close friend. The nurse determines that an appropriate nursing diagnosis for this client is Readiness for Enhanced Coping. What type of nursing diagnosis is Readiness for Enhanced Coping?

wellness

How should a nurse best document the assessment findings that have caused the nurse to suspect that a client is depressed following a below-the-knee amputation?

"Client states, 'I don't see the point in trying anymore.'"

The nurse is caring for a client who is taking nitroglycerin. Which client statement requires immediate nursing intervention?

"I am taking tadalafil in addition to nitroglycerin."

Which statement by a client indicates to the nurse that teaching was effective regarding the different parts of a syringe?

"The plunger is the part of the syringe that moves back and forth to withdraw and instill medication."

Which assessment should be conducted by the nurse before the nurse administers tuberculin intradermal injection?

checking for documented allergies to food or drugs

The nurse is preparing to administer an allergy test intradermally. At what angle will the nurse plan to insert the needle into the client?

10-15

A nurse is administering a piggyback infusion to a client with partial-thickness or second-degree burns. Which describes the most important feature of a piggyback infusion?

A parenteral drug is given in tandem with an IV solution.

The client is prescribed a medication that needs to be taken on an empty stomach. The nurse inadvertently administers this medication with food. What are the ramifications of this error?

Absorption of the medication will be impaired.

The nurse is preparing to interview a client who demonstrates significant abdominal pain and rates the pain at 10 on a 0 to 10 pain scale. What action by the nurse can improve the outcome of the interview?

Administer prescribed pain medication prior to conducting the interview.

During examination a client becomes very tired but still needs to answer questions so that the nurse has sufficient data for planning care. Which action by the nurse would be most appropriate in this situation?

Ask the client whether it is okay to interview the client's spouse for the answers to the interview questions.

A nurse has selected a nursing diagnosis and is preparing to validate it. With whom would the nurse do this?

client

A homeless client in the public health clinic has a strong body odor and is wearing clothes that are visibly soiled. What nursing diagnosis would be most appropriate for the nurse to identify?

Bathing Self-care Deficit related to lack of access to bathing facilities as evidenced by a strong body odor

Which group of terms best defines assessing in the nursing process?

Collection, validation, communication of client data

Which example of client care is not the responsibility of the nurse?

Confirming a medical diagnosis

A newly graduated nurse is unable to determine the significance of data obtained during an assessment. What would be the nurse's most appropriate action?

Consult with a more experienced nurse.

Which is the best source of information for the nurse when collecting data for an assessment?

client

The nurse plans discharge teaching for a client leaving the medical center with new medication prescriptions. Which action(s) does the nurse include in the discharge teaching? Select all that apply.

Explain the benefit in placing medications in a place that links to normal events in the client's life such as brushing teeth or going to bed Provide client with a list of medications and directions for taking them Confirm that the client understands the reason for the medications Teach client and caregivers how to fill a pill box using the medicine list as a guide

The nurse is preparing to conduct an assessment on a new client of Chinese descent who is being admitted for abdominal surgery. Which step should the nurse prioritize during the assessment with this client?

Explain the nurse will need to touch the client during the assessment

A nurse documents the following nursing diagnosis on a client's plan of care: "Fluid Volume Deficit related to gastrointestinal upset from food poisoning as evidenced by vomiting and diarrhea for the past three days, slow skin turgor, and weight loss." The nurse identifies which part of the statement as the etiology?

GI upset from food poisoning

A nurse is explaining to a client the correct method of using a metered-dose inhaler when self-administering a prescribed dose of medication. What is a feature of a metered-dose inhaler?

It is a canister that contains pressurized medication.

A nurse is caring for a client who has been prescribed codeine, a narcotic medication to relieve severe postoperative pain. Which responsibility does the nurse have to complete when handling narcotic medications? Select all that apply.

Maintain an accurate account of the use of the medication. Record each medication used from the stock supply. Count each narcotic medication at the change of each shift.

What association meets every 2 years to further progress in defining, classifying, and describing nursing diagnoses?

NANDA

The nurse has identified a collaborative problem of Risk for Complications of Electrolyte Imbalance for a client with diarrhea. The client begins to exhibit a decrease in level of consciousness. What is the nurse's most appropriate action?

Notify the physician for additional orders.

The nurse is assessing a client who was seen 7 days ago with strep throat. The client states, "I felt better after 2 days of the antibiotic the provider prescribed, so I quit taking it." What would the nurse do to address this situation?

Provide education on taking all antibiotics for effective treatment

While administering a medication via a syringe, a client sharply moves and the nurse accidentally encounters a needlestick. What is the priority nursing action?

Report the needlestick to the nurse manager.

The nurse is preparing to administer a tuberculin test to a client. Which instructions should the nurse provide to the client?

Return in 48 to 72 hours for results.

A client diagnosed with advanced lung cancer has a nursing diagnosis of Ineffective Coping. What assessment data would provide evidence to the nurse for this diagnosis?

The client states, "I am sure the doctors have misdiagnosed me."

Regarding medication administration, what must occur at the change of shifts?

The narcotics for the division are counted.

During morning report, the night nurse tells the day nurse that the client refused to allow the technician to draw blood for laboratory testing. What step would be essential for the day nurse to complete before selecting a nursing diagnosis to address this issue?

The nurse should determine the reason for the client's refusal.

A postoperative client's medication administration record (MAR) provides for PRN administration of a number of analgesics by various routes. Which action should the nurse take to assess the client's pain to determine the appropriate analgesic to administer?

The nurse will have the client rate pain on the pain scale of 1 to 10 and proceed accordingly.

Which statement best describes the nurse's rationale for selecting the ventrogluteal site when using the Z-track technique for administering an injection?

The ventrogluteal site provides a location with the capacity for depositing and absorbing the drug.

"Acute Pain related to instillation of peritoneal dialysate as evidenced by client wincing and grimacing during procedure, client description of experience as 'stabbing'" is an example of which type of nursing diagnosis?

actual diagnosis

A client has been ordered nasal drops, which the nurse will administer. How should the nurse best position the client?

Upright, with head tilted back

A client with chronic obstructive pulmonary disease (COPD) has been prescribed an inhaled bronchodilator. Which technique should the nurse implement in order to ensure safe and complete delivery of the prescribed medication?

Use a spacer or extender with the metered-dose inhaler.

A nurse is performing an admission assessment on a client who is scheduled for an elective surgery the next morning. When taking vital signs, the nurse finds that the client's temperature is 39.4°C (103°F). What should be the nurse's priority action?

Verbally report the finding immediately to the client's physician.

Which client would most likely require placement of an implantable port?

a 58-year-old woman with stage 3 breast cancer requiring weekly chemotherapy

A physician at a health care facility suggests the use of a metered-dose inhaler for an asthmatic client. Which describes the mechanism of a metered-dose inhaler?

a canister containing medication that is released when the container is compressed

Which statement by a new nurse regarding validation of data collected during client assessment indicates a need for further training?

all data collected needs to be validated

A client is receiving home care due to an unstable blood pressure. Which nursing intervention is a priority?

assess their BP

When preparing to administer a second dose of a prescribed vaginal suppository, the client reports discomfort in the vaginal area. What should the nurse do next?

assess vaginal area

The client states "I think my IV dressing needs to be changed." In which instance should the nurse change the dressing?

bloody, loose, or wet

During the initial assessment of a newly admitted client, the nurse has clustered data as follows: range of motion with gait, bowel sounds with usual elimination pattern, and chest sounds with respiratory rate. The nurse is most likely organizing assessment data according to:

body systems

The nurse is assessing a client who reports abdominal pain. Which assessment technique will the nurse perform first?

inspection

A nurse is administering an injection to a client at a 15-degree angle. The client has a venous access port. Which injection can be administered at this angle?

intradermal

The nurse is preparing to administer a tuberculin test. Which route will the nurse select to administer this injection?

intradermal

The nurse recognizes which routes for parenteral medication administration? Select all that apply.

intradermal subcutaneous intravenous intramuscular

If the dosage is inappropriate for a client, who is responsible?

nurse

After performing the admission assessment on an older adult client, the nurse documents the following, "Client observed fidgeting with covers; facial grimacing when turning from side to side." This documentation is an example of which type of data?

objective

Which nursing skill uses all five senses?

obversation

The physiologic and biochemical effects of a drug on the body defines:

pharmacodynamics

The chemotherapy client has been admitted for thrombocytopenia. Which blood product will the nurse anticipate administering?

platelets

Which technique should the nurse employ when instilling otic medication in an adult ear?

pull up and back

A nurse is administering a prescribed intramuscular injection to a client by the Z-track method. Which action ensures that the medicine remains sealed?

pulling the tissue laterally until the tissue is taut

What should the nurse do prior to performing an initial assessment on a newly admitted client?

review the records

What would be considered a "right" of drug administration? Select all that apply.

right drug right documentation right client right dose

A nurse is preparing to administer a scheduled dose of enteric-coated ASA to a client who has a history of angina. When preparing the medication, the nurse is careful to check the five rights of medication administration. The five rights include which of the following?

right time

A client with HIV has been admitted to a health care facility. Which nursing diagnosis should be the priority, keeping in mind the client's condition?

risk for infection

A client comes to a health care facility reporting abdominal pain and vomiting. The client's spouse informs the nurse that the client went out for dinner the previous night. The report that the client went out for dinner the previous night is example of data from which type of source?

secondary

A client who has been receiving a secondary infusion of a new antibiotic for several minutes reports itching and a sensation of throat tightness. What is the priority nursing intervention?

stop the infusion

A client describes pain in the right leg as aching at 8/10 on a pain scale. What type of cue is a client's description of pain in the right leg?

subjective

Drugs known to cause birth defects are called:

teratogenic

The nursing instructor is teaching students about assessment and the importance of having baseline data when caring for clients. The instructor should inform the students that the best place to get baseline data is:

the initial comprehensive client assessment.

A nurse caring for a client with a respiratory condition notices the client's breathing pattern is getting more irregular and the rate has greatly increased from 18 to 32 breaths per minute. The nurse notes that this client's vital signs are assessed once every shift, but believes the assessment should be done more frequently. Who is responsible for increasing the frequency of this client's assessments?

the nurse

A nurse practitioner in private practice with a physician is providing psychiatric care to a client with a history of being abused by a spouse. During the last visit, the client stated an intent to leave the spouse. In the next visit, the nurse practitioner will reassess the client's commitment to this intended change. What type of assessment is the nurse practitioner implementing?

time lapse