Fundamentals

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

Cleanse the wound from the center outwards

A client is receiving continuous tube feeding via NG tube. The client has 3 episodes of vomiting in 12 hr. Which of the following actions should the nurse take?

Aspirate for residual

The nurse is caring for a client receiving fluid through a peripheral IV catheter. Which of the following findings at the IV site should the nurse recognize as infiltration?

Skin blanching

A nurse is planning care for a client who has dysphagia following a stroke. The nurse should initiate a referral for which of the following therapies?

Speech therapy

A charge nurse is observing a newly hired nurse preparing a sterile field. Which on the following indicated to the charge nurse that the sterile field is contaminated?

Sterile field is opened on a wet surface

A nurse in a long-term care facility is planning to preform hygiene care for a new resident. Which of the following assessment questions is the nurse's priority before beginning this procedure?

"Are you able to help with your hygiene care?"

A nurse is caring for a client who is scheduled to be transferred to a long-term care facility. The client's family questions the nurse about the reasons for the transfer. Which of the following responses made by the nurse is appropriate?

"Have a seat and let me tell you what had happened"

A nurse is caring for a client who needs a 24-hr urine collection initiated. Which of the following client statements indicates an understanding of the procedure?

"I flushed what I urinated at 7 a.m. and have saved all urine since."

A hospice nurse is providing end-of-life care to a client who has terminal lung cancer. The client states, "I am so tired and afraid of not being able to catch my breath." Which of the following is an appropriate response by the nurse?

"I will be able to give you a medication to help your breathing."

A nurse is providing teaching to a client who is receiving chemotherapy. Which of the following client statements indicates an understanding of the teaching?

"I will disinfect my toothbrush weekly"

A nurse is educating a family member of a client who is immobile about how to prevent back injury associated with moving client up in bed. Which of the following statements by the family member should indicate to the nurse that he understands the teaching?

"I will leverage my weight against my wife and shift it as I mover her"

A nurse is speaking with the parent of an infant who has cardiac defect. After the parent expresses concern, which of the following is an appropriate response?

"Tell me about your baby while I bathe her"

A nurse on an oncology unit is caring for a client who has tears in his eyes and states, "The doctor just told me that I don't have long to live." Which of the following is an appropriate response by the nurse?

"Tell me more about how you're feeling"

A nurse is caring for a client who reports pain. When documenting the quality of the client's pain on an initial pain assessment, the nurse should record which of the following client statements?

"The pain is like a dull ache in my stomach"

A nurse has accepted a verbal prescription from three tenths of a milligram of mevothyroxine IV stat for a client who has myxedematous coma. How should the nurse transcribe the dosage of this medication in the client's medical record?

0.3mg

A nurse is caring for a client who has a NG tube that is irrigated every 8 hr. Which of the following should be used to irrigate the tube in order to maintain fluid and electrolyte balance?

0.9% sodium chloride

A nurse is preparing to obtain a lower extremity blood pressure from a client and no longer palpates the popliteal pulse after 92 mm hg. Which of the following images displays the appropriate mm Hg to which the nurse should inflate the cuff when obtaining the blood pressure?

122 30 over

A nurse is caring for a client who has take in 2,600 ml of fluids in 24 hours. Which of the following is an expected output for the client?

2,500 ml

A nurse is preparing to administer ampicillin 40mg/kg/day PO divided in equal doses every 6 hr to a toddler who weights 10 kg. Available os ampicillin oral suspension 125mg/5ml. How many ml should the nurse administer per dose? (Round the answer to the nearest whole number.

4

A nurse is caring for a client with cancer who lives at home with her spouse. The spouse tells the nurse that the client is in pain "all of the time." Which of the following actions is the most important for the nurse to take?

Ask the client to rate her pain

A nurse is planning care of an adolescent who is postoperative following a lumbar laminectomy. Which of the following interventions should the nurse include in the plan of care?

Allow the adolescent to make decisions regarding his daily routine.

A nurse is conducting a respiratory assessment for four clients. Which of the following should the nurse recognize as an abnormal respiratory assessment finding?

An adolescent who has visible accessory muscle movement when breathing

Which of the following techniques should the nurse use when preforming nasotracheal suctioning for a client?

Apply intermitten suction when withdrawing the catheter

A nurse is transcribing new orders for insulin based on a client's blood glucose readings. The nurse notes that the provider did not write the frequency for checking blood glucose levels on the order sheet. Which of the following is the appropriate action by the nurse?

Call the health care provider to determine the frequency of blood glucose checks

A nurse is providing discharge teaching for a client who has a new prescription for a home oxygen concentrator. Which of the following instructions should the nurse give to the client and his family?

Check the cords routinely fro frays or tearing Consider purchasing a generator for power backup Monitor for signs of hypoxia

A nurse is providing teaching to a client about techniques to promote sleep. Which of the following instruction should the nurse include in the teaching?

Consume a light snack of carbohydrates at bedtime

A nurse is caring postoperative adult client who refuses to use an incentive spirometer following major abdominal surgery. Which of the following is the nurse's priority action?

Determine the reasons why the client is refusing to use the incentive spirometer

A nurse is preparing a change- of -shift report. Which of the following is an appropriate method to communicate continuity of care?

Situation, background, assessment, and recommendation (SBAR)

A charge nurse is discussing the responsibility of nurses caring for clients who have a Clostridium difficile. Which of the following information should the nurse include in the teaching?

Have a family member wear a gown and gloves when visiting

A nurse is preparing to administer meperidine 80 mg IM from a 100 mg prefilled syringe. After the injection, which of the following is an appropriate action by the nurse?

Have another nurse witness the disposal of the excess medication

A nurse is performing a Romberg's test during the physical assessment of a client. Which of the following techniques should the nurse use?

Have the client stand with arms at side and feet together

A nurse is caring for a client for whom a nasogastric tube is ordered from stomach decompression. Which of the following actions is appropriate when inserting the NG tube?

Have the client take sips of water to promote insertion of the NG tune into the esophagus

A nurse is reviewing practice guidelines with a group of newly licenses nurses. Which of the following interventions falls within the RN scope of practice?

Initiate an enteral feeding through a PEG tube

The nurse is caring for a client with an order for 5 unites regular insulin and 10 units of NPH insulin to be mixed together and administered subcutaneously. List the correct order of steps for the procedure.

Inject 10 units of air into the bottle of NPH insulin Withdraw the correct dose of NPH insulin from the bottle Inject 5 units of air into the bottle of regular insulin Withdraw the correct dose of regular insulin from the bottle

A nurse is caring for a client following an acute myocardial infarction. The client is concerned that providing self-care will be difficult due to extreme fatigue. Which of the following strategies should the nurse implement to promote the client's independence?

Instruct the client to focus on gradually resuming self-care tasks

Which of the following should indicate to a nurse the need to suction a client's tracheostomy?

Irritability

A nurse is preparing to transfer a client from the bed to the stretcher using a slide board. Which of the following actions should the nurse take?

Lower the head of the bed

A nurse is reinforcing teaching regarding the use of a cane to a client who has left-leg weakness. Which of the following should the nurse include in the teaching?

Maintain two points of support on the floor

A nurse is preforming assessments on clients of various ages. Which of the following is an appropriate physical assessment technique?

Measurement of an adult;s blood pressure with a cuff whose bladder surrounds 80% of the client's arm circumference

A nurse is transcribing new prescriptions for a client. Which of the following prescriptions is accurately transcribed by the nurse?

Morphine 4 mg IV bolus every 2 hr PRN for incisional pain

A nurse is assisting a client with range-of-motion exercises of the neck. Which of the following should the nurse suggest to promote neck rotation?

Move her head from side to side

A nurse is preforming a peripheral vascular assessment for a client. When placing the stethescope on the client's neck she hears the following sound. This indicated which of the following? (blowing or forcing the blood through the arteries

Narrowed arterial lumen

A nurse is providing teaching about a clear liquid diet. Which of the following should the nurse instruct the client to avoid?

Orange sherbet

A nurse is caring for a clinet receiving IV fluids. During a routine check the nurse determines that the client has developed phlebitis and removes the IV catheter. Which of the following actions should the nurse take next?

Place a warm compress over the IV site

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

Place the client in a negative pressure room Wear gloves when assisting the client with oral care Use antimicrobial sanitizer for hand hygiene

A nurse is caring for a client who is having difficulty voiding following the removal of an indwelling urinary catheter. Which of the following actions should the nurse take?

Pour warm water over the clinet's perineum to create the sensation to urinate

A nurse is completing an admission assessment of an older adult client. Which of the following findings is a potential indication of abuse?

Presence of bruises on the arms in various stages of healing

A nurse is obtaining a health history from a client who has hearing loss. Which of the following actions by the nurse is appropriate?

Rephrase rather than repeat misunderstood information

A nurse is caring for a client in the immediate postoperative period. The nurse should recognize that which of following positions maximizes the effectiveness of incentive spirometry?

Semi-Fowler's

A nurse is reviewing the medical records for a client who has a pressure ulcer. Which of the following is an expected finding?

Serum albumin level of 3 g/dL

A nurse in a long-term care facility notes that a client coughs frequently during meals and suspects dysphagia. The nurse should assess the client for which of the following behavioral signs of dysphagia?

Storing food in the mouth

A nurse is planning to delegate client care to an assistive personnel (AP). Which of the following factors is most important for the nurse to consider before delegating care?

The facility's job description for the AP

A nurse is reviewing a protocol in preparation for suctioning a client who has a new tracheotomy. Which of the following is an appropriate action for the nurse to take?

The nurse should select a suction catheter that is half the size of the lumen to prevent hypoxemia and trauma to the mucosa.

A nurse preparing to insert an IV catheter into a client's arm prior to initiating IV fluid therapy. Which of the following interventions should the nurse implement to prevent infection?

Thread the IV catheter so that the hub rests at the insertion site

A nurse is caring for a client who has dementia. Which of the following interventions should the nurse take to minimize the risk for injury to this client?

Use a bed exit alarm system

A nurse is caring for a client who has left-sided paralysis after a cerebrovascular accident. The client is unable to bear his own weight. Which of the following actions is an appropriate method to move the client from his bed to his wheelchair?

Use a hydraulic lift and have a AP help move the client

A nurse is evaluating a client who has right leg weakness and is learning to use a rubber-tipped standard walker. Which of the following actions by the client indicates proper use of the walker?

Uses a lifting motion to move the walker

Which of the following precautions is important to take when a nurse is caring for a client who had diarrhea due to Shigella?

Wash hands before and after client contact

A nurse is caring for a client who is refusing a scheduled blood transfusion for religious reasons. The client's partner wants the client to have the blood transfusion. Which of the following actions should the nurse take?

Withhold the scheduled blood transfusion

A nurse is implementing a plan of care for an older adult client who is at risk for falls. Which of the following is an appropriate nursing action?

implement a regular toileting schedule