Fundamentals Midterm sp21 wk1-9 practice

a provider is discharging a client with a prescription for home oxygen therapy. The nurse should reinforce which of the following instruction with the client and his family?

- make sure the straps on the mask are secure but not too tight. - check the tops of his ears regularly for skin breakdown - post "No Smoking" warning signs at home in a prominent location

a nurse in an extended care facility is reinforcing teaching for with a group of newly licensed nurses and expect this psychological changes of Aging. Which of the following information should the nurse include?

-more difficulty pain due to a greater sensitivity to glare. rationale: older adults have an increased susceptibility to glare, greater difficulty seeing in dim lighting, and alteration in color perception. - decrease cough reflex rationale: older adults have a decreased cough reflex, increase Airway resistance, fewer alveoli, and a greater risk for respiratory. - decreased bladder capacity rationale: older adults have a decreased bladder capacity and a reduction in renal blood flow. - dehydration of intervertebral discs rationale: older adults have dehydration of intervertebral discs, decreased muscle strength and mass, and decalcification of Bones.

a nurse is caring for a client who reports constipation the provider has prescribed an enema identify the sequence of steps the nurse should take to administer the enema.

1. confirm the client's identity by checking her wristband 2. provide for the clients privacy by closing the curtains 3. assisted client into a Sims position 4. insert the tip of the enema tube into the patient's rectum

a nurse is caring for a client who is post-operative. When helping to manage the client's pain, which of the following principles should the nurse apply?

1. consider the client's individual expression of pain 2. use a scale from 0 to 10 to monitor the severity of the clients pain

a nurse is preparing a sterile field for the insertion of urinary catheter. Identify the sequence of action the nurse should follow.

1. perform hand hygiene 2. place the sterile package on the work surface 3. open the outermost flap away from the body 4. open the side flaps 5. open the innermost flap towards body 6. use the inner surface of package as a sterile field

a nurse is caring for a client who has metabolic alkalosis. for which of the following clinical manifestations should the nurse monitor?

1. shallow respiration 2.cardiac dysrhythmias 3.hyperactive reflexes

a nurse is inserting an NG tube. Identify the sequence a nurse should follow.

1.Place client in high Fowler position 2.measure tube for placement 3.lubricate the tube 4.insert tube along the base of nares. 5.advance tube downward and backward 6.check position of tube and secure

a nurse is discussing indications for urinary catheterization with a newly licensed nurse. Which of the following indications should the nurse include?

1.relief of urinary retention 2. measurement of residual urine after urination 3. presence of an open perineal wound

a nurse is caring for a client who is in contact isolation. When exiting the client's room, and what order should the nurse take the following steps when removing her personal protective equipment?

1.remove gloves 2. remove protective eyewear 3.remove gown 4. remove mask 5.perform hand hygiene

a nurse is reviewing blood pressure classifications with a client who has been newly diagnosed with hypertension. Which of the following should the nurse include as an example of stage 1 hypertension?

154 / 96 mm hg rationale: stage 1 hypertension include systolic BP 140 to 159 mm hg or diastolic BP 90 to99 mm hg. this is an appropriate example for the nurse to include

a nurse is caring for a client who has a prescription for digoxin 0.25 mg PO daily. The amount of available is digoxin 0.125 mg tablet. How many tablets should the nurse administer per dose?

2 tablet(s) ​

a nurse is caring for a client who has impaired renal function. The nurse should notify the provider a surprise hourly urine output Falls below what amount?

30 ml

a nurse is preparing to administer amoxicillin 320 mg PO every 12 hours to an infant. The amount of available amoxicillin suspension 400 mg / 5 ml. How many ml should the nurse administer per dose?

4 ml

a nurse is caring for a client who requires an NG tube. After inserting the tube, the nurse test is the pH of the client's aspirate. Which of the following pH level should the nurse identify as an indication of correct placement of the tube?

4.0 rationale: this is an acidic pH, which indicates gastric drainage. The tube is likely to be in the stomach.

a nurse is preparing to insert an indwelling urinary catheter for a female client. After opening the catheter kit and preparing to supplies, which of the following steps should the nurse perform next?

Don sterile gloves rationale: according to evidence based practice, the nurse should Don sterile gloves next. Urinary catheterization is an invasive procedure; therefore, it require surgical asepsis to reduce the risk of infection.

a nurse is preparing to administer a bolus enteral feeding to a client who has a gastrostomy tube. Which of the following actions should the nurse take first?

Elevate the head of the bed rationale: the greatest risk for a client is injury from aspiration; therefore, the first action is to elevate the clients had are the bed into high Fowler position, or at least 30 degree to 45 degree

a nurse is reviewing the laboratory results of a client who has a pressure ulcer. The nurse should identify an elevation in which of the following laboratory values as an indication that the client has developed an infection?

WBC rarionale: an elevation in white blood count indicates that the patient's immune system is defending him against a pathogen causing infection.

a nurse is collecting data about the fluid status of four clients. Which of the following clients should the nurse identify as being at risk for fluid volume deficit?

a client who has gastroenteritis and is receiving oral fluids rationale: gastroenteritis causes diarrhea and vomiting, so it can be a significant source of fluid loss. the nurse should identify this client as having a risk for fluid volume deficit.

a nurse is discussing pressure ulcer staging with a newly licensed nurse which of the following statements should the nurse use to describe a stage 3 pressure ulcer?

a deep crater without visible bone, tendon, or muscle rationale: a state's report pressure ulcer is deep and might or might not have under my name. It extends down two layers of skin and subcutaneous tissue, but does not have visible support tissue (bone, tendon, or muscles).

a nurse is caring for an older adult client who has constipation. Which of the following actions should the nurse take?

add fluid and fiber to the diet rationale: to help relieve constipation, the nurse should instruct the client to drink more water hot fluids such as water with lemon juice and eat foods that are high in fiber such as whole-grain bread brand and raw fruits.

a provider prescribes a sublingual medication for a client who has an NG tube in place. Which of the following actions should the nurse take?

administers medication under the client's tongue rationale: the nurse should administer the sublingual medication under the client tongue. Sublingual preparation work via direct absorption into the bloodstream. Swallowing it exposes it to the gastric juices, which can inactivate it.

a nurse on a medical unit is coochie a group of nursing students about the variety of Rose nurses assume while working with clients. The nurse should explain that which of the following rules focuses on protecting the client and supporting the clients decisions?

advocate rationale: Appliance Advocate act to protect your clients rights and helps the client speak for themselves.

a nurse is planning care for a group of clients. When planning the assignment for an assistive Personnel AP, which of the following activities should the nurse consider unsafe for the AP to perform?

assisting an older adult client to take acetaminophen the AP crushes in applesauce rationale: only licensed nurses May administer medications

a nurse is caring for a client who has a prescription for a stool gualac test. the client yeah ask the nurse about the purpose of the test. The nurse should respond by stating that the stool gualac is testing for which of the following findings in the client feces?

blood rationale: a gualac (fecal occult blood) test detects microscopic amounts of blood in the stool and is a screening tool for colorectal cancer.

a nurse enters a client's room and finds the client pulseless. The nurse knows the client's family has requested do-not-resuscitate DNR status from the provider, but the provider has not written prescription yet. Which of the following actions should the nurse take?

call the emergency response team rationale: unless the Provider writes a DNR prescription, the nurse must make every effort to resuscitate the client. The nurse should follow the facilities protocol for initiating the emergency response procedure.

a nurse is collecting data about a client's circulatory system. Which of the following pulse sites should the nurse avoid checking bilaterally at the same time?

carotid rationale: the nurse should avoid evaluating the carotid pulse bilaterally at the same time. this action cannot induce syncope by reducing blood flow to the brain and causing a reflex drop in the blood pressure and heart rate

a nurse in a long-term care facility finds an older adult client lying on the floor next to the bed. Which of the following actions should the nurse take?

check the client for injuries rationale: the quiet might have sustained a fracture or a head injury. It is the nurses responsibility to check for the client for injury after a fall.

a nurse is caring for a client who came to the emergency department with abdominal distention and is now on the medical-surgical unit with a NG tube in place to gastric suction. The client reports anxiety, discomfort, and a feeling of bloating. which of the following actions is the nurses priority?

check to see if the suction equipment is working rationale: the first action the nurse should take using the nurse process is to collect data. the nurse should checked for the most obvious reason why they're clients symptoms have returned. But this section equipment has malfunction, the nurse should have guessed it or replace it with a working equipment.

walk looking data from an older adult client, the nurse learns that the client has a difficulty sleeping at night for several months. When evaluating the client's sleep disturbance, the nurse should factor in which of the following principles that can affect older adults and sleep?1

chronic pain and illness interfere with the sleep pattern of older adults rationale: chronic pain Eleazar common causes of interrupted sleep in older adults. The nurse should evaluate declines further for contributing factors such as these

a nurse is caring for a client who has a wound infection. Which of the following actions should the nurse take when obtaining a wound drainage specimen for culture?

cleanse the volume with 0.9% sodium chloride irrigation before obtaining the specimen. rationale: the nurse should remove all wound exudate and any residual antimicrobial ointment or cream to avoid altering the culture results.

a nurse is about to give a client a complete bed bath. Which of the following actions should the nurse take to maintain the clients privacy?

close the curtains around a client's bed. rationale: closing the curtains around Appliance bed ensures privacy for the client should a visitor or another staff member open the door or into the room.

a nurse is checking the apical pulse of a client who is taking several cardiovascular medications. Which of the following actions should the nurse take?

count the apical pulsations for a full minute. rationale: for clients who have a regular pulse and no cardiovascular problems, the nurse should count the apical pulsation for 30sec and multiply by 2. For this client, the nurse should count for 60 seconds.

a nurse is caring for a client who has pneumonia and has been receiving oxygen therapy for several days. when collecting data from the client, the nurse should identify which of the following findings as an indication of an adverse effect of oxygen therapy?

cracks in oral mucous membranes rationale: oxygen therapy, especially when long-term or without sufficient humidification, is extremely drying to the NAT nasal and oral mucosa and can cause cracks

a nurse is assisting in preparing a presentation at a senior center about age-related musculoskeletal changes. Which of the following alterations is appropriate for the nurse to include?

decrease muscle mass rationale: with aging, muscles decrease in mass and strength.

a nurse is caring for a client who requires contact precautions. Which of the following actions should the nurse take?

dedicate equipment and supplies for used with the client rationale: the nurse should use non-critical equipment such as stethoscope for use with the client only, and leave it in the clients room to prevent spreading the clients infectious organisms to other clients and staff

a nurse is caring for an older adult client in a long-term care facility. Which of the following measures should the nurse first take when assisting with planning the clients care?

determining the client's Mobility rationale: the greatest risk to this client is injury from moving without assistance if he has impaired mobility; therefore, the priority action is to collect data from the clients mobility and needed for assistance with transferring and ambulating.

a nurse is caring for a client who is receiving enteral tube feedings of a diluted formula. Which of the following complications of enteral tube feeding should a nurse identify as a reason to administer diluted feeding to clients?

diarrhea rationale: Jerry we are required by looting the formula to replace lost water, reducing the rate of delivery, were administering and isotonic enteral formula.

the nurse is caring for a client who requires a clear liquid diet. Which of the following foods should the nurse allow the client to have?

grape juice rationale: a clear liquid diet includes foods that are fluids and clear at body or room temperature. this includes apple and grape juices, broth, black coffee, and plain gelatin

a nurse assisting with a staff in-service is discussing aspiration. which of the following descriptions should the nurse include in the teaching as a manifestation dysplasia?

inconsistent vocal ability after swallowing rationale: the nurse should include that sometimes who have difficulty swallowing might have silent aspiration where there is no coughing when food is aspirated

a home health nurse is caring for a client who has emphysema and has difficulty with Mobility. The client spends most of his day in a reclining chair. Which of the following psychological responses to prolonged immobility should the nurse expect?

increase calcium excretion rationale: prolonged immobility leads to the breakdown of bone tissue. This results in increased calcium excretion

a nurse is measuring an adult clients tympanic temperature. Which of the following actions should the nurse take?

insert the probe with a circular motion rationale: the nurse should use a circular motion to insert the probe until it fits snugly within the clients ear canal

a nurse is caring for a client who practices Orthodox Judaism. The nurse should identify that which of the following food together on the same dinner tray and violates the client's religious practices?

kosher roast beef and ice cream rationale: kosher dietary restrictions prohibit mixing me and milk products at the same meal. The nurse should make sure that the tray and dietary Department provides for this client do not have meat and dairy items together

a nurse is collecting data from an older adult client who has had some bone density loss. The nurse observes excessive for curvature of the thoracic spine. The nurse send document this finding using which of the following terminology?

kyphosis rationale: kyphosis, a forward "hunchback" curvature of the spine, is an abnormal angulation of the posterior curve of the thoracic spine, usually a result of osteoporosis. it is most common in older adults and tends to increase with aging.

a nurse is assisting a client who has generalized weakness out of the bed to a wheelchair. Which of the following actions should the nurse take?

lock the Wheels of the bed and the wheelchair. rationale: the nurse should keep the wheels of the bed and the wheelchair in the lock position to prevent them from moving when transferring a client.

a nurse is measuring the vital signs of a client he suspect has hypovolemic shock. Which of the following findings should the nurse expect?

low BP and high pulse rate rationale: shock is a serious complication that develops from a lack of adequate blood flow, decreased tissue perfusion, and decreased cardiac output. Vital Signs reflecting shock include low blood pressure, increased respiratory rate, and a rapid pulse as a cardiovascular system tries to compensate.

a nurse is administering a tap water enema to a client. The client reports cramping as a nurse instills the irrigating solution. which of the following actions should the nurse take to relieve the client's discomfort?

lower the height of the solution container rationale: if nausea or cramping occurs, the nurse should slow the flow of the water, leaving the tube in place. The nurse should then raise the solution container when the cramping has passed.

after signing a informed consent form, a client tells the nurse, " I have changed my mind and do not want to have the procedure." which of the following actions should the nurse take?

notified the surgeon that the client wishes to withdraw informed consent for the procedure. rationale: the client has the right to withdraw informed consent; therefore, the nurse should notify surgeon of the change in the client's wishes.

a nurse is caring for a client who has an infection. The nurse should use which of the following strategies to interrupt the transmission of the client's infection?

performing hand hygiene before, during, and after direct contact with a client rationale: the nurse interrupts the transmission of microorganisms, by removing them from her hands frequently before, during, and after client care procedures.

A nurse in a community clinic is collecting data from a client who reports frequent vomiting and diarrhea for the past 3 days. which of the following findings should the nurse expect?

poor skin turgor- frequent vomiting and diarrhea cause dehydration, which manifests as skin that lacks elasticity. hypotension- frequent vomiting and diarrhea cause dehydration, which manifests as hypotension. flat neck veins- frequent vomiting and diarrhea cause dehydration, which manifests as flat neck veins when client is lying supine. ​

when a nurse obtains and unusual low blood pressure measurement for a client whose blood pressure is generally elevated, she considered the possibility of a problem with her technique. Which of the following sources of air should she consider as a possible cause of the low reading?

positioning the patient's arm above Heart level rationale: positioning the client's arm too high, such as on an overbed table, can cause erroneously low blood pressure readings. another possible source is a cuff with a bladder that is too wide for the client's arm.

a nurse is checking a client's file sound. I wish of the following times should the nurse ausculate the patient's abdomen?

prior to perusing the abdomen rationale: according to evidence based practice, the nurse should ausculate the abdomen prior percussing it to prevent altering the bowel sound. Both percussion and palpitation can stimulate the intestines, increase their motility, and intensify the bowel sound.

a nurse is caring for a client who has pneumonia. The clients oxygen saturation is 84%. Which of the following actions should the nurse take first?

raise the head of the bed rationale: according to evidence based practice, the nurse should first Elevate the head of the bed to reduce the client's of workload and minimize fatigue. It uses gravity to drop the abdominal organ away from the diaphragm, which allows optimal expansion of the lungs.

when auscultating a client's lungs, the nurse identifies crackles in the left posterior based. which of the following actions should the nurse take?

repeat the auscultation after asking the client to breathe deeply and cough. rationale: although crackles often indicate fluid in the alveoli, they can also develop from hypoventilation. Fine crackles sometimes clear after a deep breath or a cough. Medium and coarse crackles do not. ​

a nurse is assisting with the admission of a client who is hyperventilating, reports lightheadedness and paresthesias, and has blurred vision and a new onset of confusion. the nurse should suspect that the client has developed which of the following balances?

respiratory alkaloids rationale: Lions have had respiratory alkaloids have an increased depth with rate of respiration, confusion, lightheadedness, tremors, parenthesis, and blurred vision.

a nurse delegates the application of wrist restraints for a client who is confused to an assistive Personnel (AP). The AP padded wrist restraints and secure the straps to the bed frame with a double knot. Which of the following actions should the nurse take?

retie the restraint straps with a slipknot. rationale: a double knot prevents easy release in the event of an emergency. Slipknot's and 1/2 bonuts are types of knots that allow a quick release.

a nurse is collecting data on a clients pulmonary system. while auscultating the client's lung, the nurse hears continuous gurgling, low pitched sounds over the trachea and bronchi. Which of the following terms should the nurse use to document this finding?

rhonchi rationale: rhonchi are heart sounds similar to snoring or moaning. Are passing through swelling or obstructions causes these adventitious breathe sounds.

a nurse is caring for a client who is post-operative and has a prescription for a full liquid diet. The nurse enters the clients room to find he has just received a diet are trained. Which of the following items on the train should a nurse remove?

scrambled eggs rationale: a full liquid diet includes foods that are liquid at room or body temperature. Scrambled eggs to not liquify at room temperature. They are component of a soft diet

a nurse removes an indwelling urinary catheter that an older adult client has had in place for 2 days. The nurse should monitor the client for which of the following expected outcomes after catheter removal?

temporary urinary retention rationale: until the bladder regains is fulltone, it is common for a client civil urinary retention. If a client does not urinate for 6 to 8 hours after catheter removal, reinsertion might become necessary.

a nurse is caring for an older adult who is a start incompetent and comes to the facility with her adult son for elective cataract extraction. After the provider explains to procedure, who should the nurse have sign the consent form?

the client rationale: the client is alert incompetent and can give her own informed consent

the nurse is counting a client's apical pulse rate. Identify where the nurse should place the stethoscope to auscultate the apical pulse.

the nurse should auscultate the clients apical pulse over the apex of the heart, at the anatomical landmark of the fifth intercostal space and below the left nipple 7.6 cm(3in) to the left of the sternum.

a charge nurse is observing a staff nurse caring for a client who has multiple skin lesions from a maricela zoster infection. which of the following actions should the charge nurse identify as an indication that the nurse understands the precautions to take when caring for a client who has this infection?

the nurse wears a high efficiency particulate air (HEPA) filter mask. rationale: the nurse should wear a high efficiency particulate air HEPA filter mask when caring for a client who has an infection that requires airborne precautions, such as disseminated varicella zoster, rubella, and tuberculosis.

a nurse is reinforcing preoperative teaching with a client who will undergo a download surgery. The nurse explains that the client will wear antiembolism stockings after the procedure. When the client asked what the stockings do, which of the following responses should the nurse make?

they will improve your circulation to keep blood from pooling in your legs rationale: antiembolism stockings promote venous return from the legs, thus helping to prevent Venous Thrombosis(clot formation) and peripheral edema

a nurse is performing a wound care for an older adult client who has stage 1 pressure ulcer. Which of the following types of dressings should the nurse apply to the wound?

transparent rationale: a stage 1 pressure ulcer involves the epidermal skin only. This is a dressing that will protect from shearing. did Jesse will also allow the nurse to visualize the area of assessment purposes. A stage 1 pressure ulcer is intact skin with non blanchable redness of a localized area. It is usually over a bony prominence. Darkly pigmented skin may not have visible blanching but the color make your fur from surrounding area.

a nurse in a long-term care facility is caring for a client who is unresponsive. When performing oral hygiene for the client, which of the following actions should the nurse take?

turn the client on his side before starting Oral Care. rationale: placing the client on his side helps fluid run out of his mouth by gravity, thus preventing aspiration.

a nurse is preparing an in-service presentation about preventing healthcare-associated infections (HAIs). the nurse should include which of the following as a common cause of these infections?

urinary catheterization rationale: invasive nursing procedures are common cause of HAIs. these include urinary catheterization, IV infusions, and administration of parenteral medications.

a nurse is emptying a client's urinal when she notices the urine is dark Amber, cloudy, and has a unpleasant odor. The nurse should identify that these findings are likely to be the result of which of the following?

urinary tract infection rationale: with a urinary tract infection, the urine appears cloudy and concentrated because of the presence of wbc's and bacteria. pus and bacteria can cause the unpleasant smell.

a nurse is planning to monitor a client for dehydration falling several episodes of vomiting and an increase in their clients temperature. Which of the following findings should the nurse identify as an indication that the client is dehydrated?

urine specific gravity of 1.034 rationale: the client's urine specific gravity is elevated, reflecting concentrated urine, which is Manifestation of dehydration.

a nurse has accidentally punctured his finger with a needle he used to give an IM injection to a client. Which of the following actions should the nurse take?

wash the puncture site with soap and water rationale: this action will help remove any surface contaminants from the wound.

a nurse is collecting data from a client who is isotonic fluid volume deficit. Which of the following findings should the nurse expect?

weak pulse rationale: manifestations of isotonic fluid volume deficit include a weak pulse, dry mucous membranes, decreased capillary refill, and decrease urine volume. ​

an assistive Personnel (AP) as a nurse what precautions you should take when measuring the vital signs of a client who has pneumonia. Which of the following responses should the nurse make?

wear a mask when entering the clients room. rationale: who's the client who has pneumonia requires droplet precautions, it is necessary for the PA to wear a mask while caring for the client.