Fundamentals Final Test Bank

A nurse is assessing a client who has a pressure ulcer. The nurse should recognize which of the following findings is a manifestation of a stage 3 pressure ulcer?

Necrotic subcutaneous tissue

A nurse is caring for an older adult client who has had surgery for an intestinal obstruction and has an NG tube to wall suction. Which of the following interventions should the nurse include the client's postoperative plan of care?

- Discontinue suction when assessing for peristalsis - Irrigate the NG tube with 0.9% sodium chloride irrigation solution. - Place sequential compression devices on the bilateral lower extremities. - Reposition the client form side to side every 2 hr.

A nurse is planning care for a client who is 4 hr postoperative. Which of the following actions should the nurse include in the plan of care?

- Assist the client to cough and deep breathe every hour - Administer PRN analgesics as needed - Give the client a back massage - Teach the client relaxation techniques

A nurse is caring for an older adult client. The nurse should recognize the client is at risk for which of the following physiological changes?

- Decreased gastric motility - Decreased skin elasticity - Increased pain threshold

A nurse is working with an assistive personnel (AP) while caring for a surgical client who is 1 day postoperative. Which task should the nurse take responsibility for completing.

Removing the abdominal dressing

A nurse is caring for a client who has been diagnosed with end-stage liver cancer. Which of the following responses is an indication the client is in the denial phase of the grief process?

The doctor says I only have a few months to live, but I know he is exaggerating to get me to take my medication.

A nurse working for a home health agency is assessing an older adult male client. Which of the following findings is the priority for the nurse to address?

Dysphagia

A nurse is providing postmortem care for a hospitalized patient. Nursing interventions should include?

- Bathe the patient - Place patient in anatomical position - Remove endotracheal tube

A nurse is caring for a client who has diabetes and a new prescription for 14 units of regular insulin and 28 units of NPH insulin subcutaneously at breakfast daily. What is the total number of units of insulin that the nurse should prepare in the insulin syringe?

42 units

A nurse is admitting a client who has tuberculosis and a productive cough. Which of the following types of isolation precautions should the nurse initiate for the client?

Airborne

A nurse assesses a hospice client. The assessment reveals BP 74/40, urine output 30 cc over 3 hours, poor skin turgor and skin cool to touch, resp 8 and irregular, and dysphagia. The nurse recognizes these combine assessment findings

Are signs of impending death

A nurse is assessing a client who is 2 days postoperative and auscultates bilateral breath sounds, but absent breath sounds in the bases. The nurse should suspect which of the following postoperative complications?

Atelectasis

A nurse is providing instructions for a 52-year-old client who is scheduled for a colonoscopy. The client reports that he has not had the procedure before and is very anxious about feeling pain during the procedure. Which of the following responses by the nurse is appropriate?

Before the examination, your provider will give you a sedative that will make you sleepy.

A nurse is assessing the respiratory pattern of an older adult client who is receiving end-of-life care. Which fo the following assessment findings should the nurse identify as Cheyne-Stokes respirations?

Breathing ranging from very deep to very shallow with periods of apnea

A nurse is planning preoperative care for a client who will undergo surgery. Which of the following is the priority action by the nurse?

Determine what the client knows about the surgery.

A nurse is caring for a client who is 2 days postoperative following abdominal surgery and observes that the client's wound has eviscerated. After calling for help, which of the following actions should the nurse take first?

Cover the area with a sterile dressing, moistened with 0.9% sodium chloride irrigation.

A nurse is assessing a client 1 day postoperative following abdominal surgery. Suddenly the client reports a pulling sensation and pain in his surgical incision. Which of the following actions should the nurse take?

Cover the area with saline-soaked sterile dressings

A nurse is assessing a client who is postoperative and finds the client's abdominal incision has eviscerated. Which of the following actions should the nurse take?

Cover the wound with a sterile saline-soaked dressing.

A nurse is teaching a client who has a prescription of a nasogastric tube (NG) to treat a pyloric obstruction. Which of the following rationales for the use of the nasogastric tube should the nurse include in the teaching?

Decompress the stomach

A 70 year old client is admitted to the PACU with an intravenous (IV) solution of 0.9% NaCl which is running at 125cc/hr. The nurse detects new onset of crackles in the lunch bases and distended neck veins. What is the nurse priority action?

Decrease the IV flow rate

The nurse is caring for a new diabetic client who is being taught how to administer insulin. The nurse knows that the patient care objectives have been met when the patient is able to?

Demonstrate how to fill insulin syringe and give insulin injections.

A nurse is caring for a client who has metastatic bone cancer. The client states, "I want to go home to die." The family is concerned about meeting the client's care needs at home. Which of the following actions should the nurse take?

Discuss initiating hospice care with the client and family.

A nurse caring for a client who has an infected wound removes a dressing saturated with blood and purulent drainage. How should the nurse dispose of the dressing material?

Dispose of the dressing in a biohazardous waste container.

A nurse is developing a plan of care for a client who is postoperative. Which of the following interventions should the nurse include in the plan to prevent pulmonary complications?

Encourage the use of an incentive spirometer.

A client who is scheduled for a barium swallow asks the nurse why a laxative is necessary following the procedure. Which of the following responses should the nurse make?

The laxative helps eliminate the barium.

A nurse working in an emergency room is assessing a client who has a leg wound. The nurse notes a full thickness wound with jagged edges and muscle tissue visible. The nurse should document this as which of the following types of wounds?

Laceration

A nurse manager is discussing the differences between normal and maladaptive grief with nursing staff. Which of the following findings should the nurse manager identify as being a unique component of the maladaptive grieving process?

Low self-esteem

A nurse has completed care procedures for a client who requires airborne precautions. Which of the following items of personal protective equipment (PPE) should the nurse remove last?

Mask

A nurse is selecting a qualified staff member to double check a blood label with a client ID bracelet prior to infusing a unit of blood. The nurse should identify that which of the following persons is qualified?

Oncology nurse

A nurse is completing discharge teaching with a client. Of the following barriers to learn the nurse identifies with this client, which should the nurse interpret as a need to postpone the session?

Pain

A nurse is assessing a client who is 3 days postoperative following abdominal surgery and notes the absence of bowel sounds, abdominal distention, and the client passing no flatus. Which of the following conditions should the nurse suspect?

Paralytic ileus

A nurse is caring for a client who is postoperative following abdominal surgery. Which of the following findings should indicate to the nurse the client's peristalsis is returning?

Passage of flatus

A nurse is caring for a client whose arterial blood gas results show a pH of 7.3 and a PaCO2 of 50 mm Hg. The nurse should identify that the client is experiencing which of the following acid-base imbalances?

Respiratory acidosis

A nurse is teaching a new group of assistive personnel (AP) about the importance of hand hygiene. Which of the following statements should the nurse include?

Rub all surfaces of your hands with an alcohol rub for 20 to 30 seconds.

A nurse is assessing a client's wound dressing, and observes a watery red drainage. The nurse should document this drainage as which of the following?

Serosanguineous

A nurse is changing the dressing of a client who is 1 week postoperative following abdominal surgery and notes the presence of serosanguineous drainage. The nurse should recognize that this is an indication of which of the following circumstances?

Serosanguineous drainage at this time is a manifestation of possible dehiscence.

A nurse is teaching a client about foods that are included on a clear liquid diet. Which of the following food choices made but the client indicates the need for further teaching?

Yogurt

A nurse is teaching a client who has a new prescription for ibuprofen to treat hip pain. Which of the following instructions should the nurse include in the teaching?

Take the medication with food.

A nurse is caring for a client who just returned from the PACU with an IV fluid infusion and an NG tube in place following abdominal surgery. Which of the following data is the priority for the nurse to assess?

The surgical dressing

A nurse is caring for a client who has a stage 1 pressure ulcer. Which of the following dressings should the nurse plan to apply?

Transparent dressing

A nurse is assessing a client who is experiencing chronic stress. Which of the following findings should the nurse expect.

Viral infection

A nurse is assessing a client who is 48 hr postoperative following abdominal surgery. Which of the following findings should the nurse report to the provider?

Yellow-green drainage on the surgical incision

A nurse is reviewing the arterial blood gas results of a client who the provider suspects has metabolic acidosis. Which of the following should the nurse expect to see?

pH below 7.35

A nurse is planning postoperative care for a client who is scheduled for an ileal conduit (urinary diversion) procedure. The nurse should include which of the following in the client's plan of care?

- Apply skin barrier around the stoma site - Educate the client that hematuria is expected - Monitor hourly urine output

A nurse is planning care for a client who is postoperative. Which of the following statements about pain management should the nurse consider when implementing client care?

- Each client's expression of pain may be different and individualized - PCA pumps offer a constant level of opioids within therapeutic range - Pain level and pain tolerance can be assessed using a scale from 0-10 - The client will express the feeling of pain both verbally and nonverbally

A hospice nurse is reviewing the prescriptions for a client who is receiving palliative care. Which of the following prescriptions should the nurse expect.

- Provide skin care with a moisture barrier - Administer artificial tears PRN - Perform mouth care every hour - Administer oxygen 2L/min via nasal cannula

A nurse is giving a presentation about preventing deep-vein thrombosis (DVT). Which of the following should the nurse include as a risk factor for this disorder?

- Recent long flight - Immobility

A nurse finds that a client did not receive a scheduled dose of furosemide (Lasix). Which of the following should the nurse include in the incident/variance report?

- The date of the incident - The time the patient was supposed to receive the medication - The client's vital signs

A nurse provides a back massage as a palliative care measure to a client who is unconscious grimacing, and restless. Which of the following findings should the nurse identify as indicating a therapeutic response?

- The shoulder droop - The facial muscles relax - The pulse is within the expected range

A nurse is preparing to administer morphine sulfate 2 mg IV bolus. Available is morphine sulfate 10 mg/mL. How many mL should the nurse administer per dose?

0.2 mL

A nurse is calculating the output of a client at the end of her shift. The nurse notes the following: client voided 400 mL at 1100 and 350 mL at 1430. The closed chest drainage system was previously marked at 155 mL and is now at 175 mL. The NG tube has 575 mL in drainage container, and 25 mL is emptied out of the Jackson-Pratt drainage tube. How many mL should the nurse record in the medical record as the client's output?

1,370 mL

A nurse is providing postmortem care for a client. Identify the sequence of steps the nurse should follow.

1. Make sure the provider has certified the client's death. 2. Verify the client's organ and tissue donation status. 3. Remove medical equipment from the client. 4. Cleanse the body while adhering to body-fluid precautions. 5. Attach identification tags to the body.

A nurse is teaching a group of middle adult clients about early detection of colorectal cancer. The nurse should include the American Cancer Society recommendation that men and women beginning at age 50 who are at average risk should have a fecal occult blood test (FOBT) and a colonoscopy at which of the following intervals?

10 years

A nurse is preparing to administer 40 mEq of potassium chloride in 45% sodium chloride (NaCl) 500 mL IV to infuse 10 mEq/hr. The nurse should set the IV pump to deliver how many mL/hr?

125 mL/hr

A nurse is providing teaching to an assistive personnel (AP) about caring for clients with restraints. Which of the following statements by the AP indicates an understanding of the teaching?

I will tie a restraint to the portion of the bed that moves when the head of the bed is moved.

A nurse is caring for a client who has a prescription for potassium chloride (KCl) 20 mEq PO daily. The nurse reviews the client's most recent laboratory results and finds the client's potassium level is 5.2 mEq/L. Which of the following nursing actions should the nurse take?

Call the prescribing physician and inform her of the client's serum potassium level results.

A nurse is preparing to administer a soap suds enema to a client who has constipation. As the nurse explains the procedure, the client states, "The doctor didn't tell me I was supposed to receive an enema." Which of the following nursing actions is appropriate at this time?

Check the client's medical record for the provider's prescription.

A nurse on a medical unit is caring for a client who suddenly becomes confused and drowsy. Additional data includes pulse 100/min, respiratory rate 24/min, BP 132/76 mm Hg, temperature 36.8 celcius. Which of the following actions should the nurse perform?

Complete a neurological check.

A nurse in a dialysis center is caring for a client who has a new diagnosis of end-stage kidney disease. When he arrives for his first dialysis treatment, he tells the nurse, "I decided to come today, but I am not sure if I will need to come back again this week. I am feeling much better since my discharge from the hospital and I think my kidneys are working again." The nurse should identify that this client is demonstrating which of the following Kubler-Ross stages of grieving?

Denial

A nurse manager is preparing to confront a staff nurse who is abusing alcohol. Which of the following defense mechanisms should the nurse manager expect the staff nurse to use?

Denial

A nurse is admitting a client who has a partial hearing loss. Which of the following is the priority action by the nurse?

Determine if the client uses hearing aids.

A nurse is caring for a client who has a new diagnosis of chronic kidney disease. Which of the following statements should the nurse identify as an indication of anticipatory grieving?

I just can't believe that this dialysis is going to ruin my whole life.

A nurse is caring for a client who is scheduled to have surgery. In preparing the client for surgery, which of the following actions is considered outside the nurse's responsibilities?

Explaining the operative procedure, risks and benefits

A nurse is caring for a client who has a new diagnosis of type 1 diabetes mellitus. To focus on affective learning with this client, which of the following interventions should the nurse use?

Explore the client's feelings about dietary modifications.

A nurse is assessing a client who is postoperative and has anemia due to excess blood loss following surgery. Which of the following findings should the nurse expect?

Fatigue

A nurse is preparing to teach a client who has low literacy level. Which of the following methods should the nurse plan to include?

Have short teaching sessions.

A nurse is caring for a client who has cancer and is receiving palliative care. Which of the following statements by the client indicates they understand this type of treatment?

I am hoping this will limit my discomfort.

A nurse is caring for a female client who has recurrent kidney stones and is scheduled for an intravenous pyelogram. Which of the following statements by the client should the nurse report to the provider?

I don't eat shellfish because it gives me hives.

A nurse is planning care for client who is postoperative and at risk for paralytic ileus. Which of the following interventions should the nurse plan to take to promote peristalsis?

Increase ambulation

A nurse in the PACU is assessing a who has an endotracheal tube (ET) in place and observes the absence of left-sided chest wall expansion upon respiration. Which of the following complications should the nurse suspect?

Movement of the ET tube into the right main bronchus.

A nurse is caring for an older adult client who is at risk for skin breakdown. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin?

Provide the client with a diet high in protein.

A nurse is reviewing the medical record for a client who has a health care-associated infection (HAI). The nurse should identify which of the following findings as a risk factor for acquiring an HAI?

The client is 71 years old.

A nurse is caring for a client who is postoperative. The nurse should base her pain management interventions primarily on which of the following methods of determining the intensity of client's pain?

The client's self-report of pain severity.

A nurse is reviewing the laboratory results of a client who has fluid volume deficit. The nurse would expect which of the following findings?

Urine specific gravity 1.035

A client was given a prescribed narcotic pain med at 0800. At 0900 the nurse finds the patient slumped in the chair, hard to arouse, with respirations of 6/minute. Arterial blood gases are ordered what would you expect to see in the ABG results?

pH less than 7.35