Fundamentals of Nursing Care-FINAL Practice Test

1. The wife of an older adult who has been admitted to the hospital with kidney failure tells the nurse, "I know he doesn't want to die in a hospital, but it's so hard for me to take care of him at home. He said he doesn't want any more treatment, but I'm not ready to let him go. We have so many arrangements to decide before he dies." Which statement by the nurse to the client's wife would be most appropriate? Select all that apply.

1. "What are your fears about your husband dying?" 2. "I can imagine that it's hard for you to care for him at home." 3. "What do you and your husband know about advance directives?" 5."We can discuss types of hospice and home care available." 6. "What kind of arrangements do you think need to be made before he dies?"

A client with newly diagnosed chronic obstructive disease is to be discharged home with oxygen per nasal prongs. Which teaching points should the nurse include in this client's discharge plan? Select all that apply.

1. Avoid areas where people are smoking cigarettes or cigars. 2. Place gauze between the ears and oxygen tubing to prevent skin irritation. 3. Request a large, pressurized oxygen tank for use during car travel.

During the last 8 hours, a nurse cared for a client who had a transurethral prostatectomy. The client has continuous bladder irrigation (CBI) infusing. At the end of the 8 hours, a nurse determines that the client received 3,050 mL of irrigation fluid and that 4,030 mL of fluid was emptied from the urinary drainage bag. The nurse calculates the actual urine output for 8 hours to be _______ mL.

980 ml

A nurse is assessing a client who was just admitted to a surgical unit following abdominal surgery. Which assessment finding would require an immediate intervention by the nurse?

A round JP drain with 20 mL serosanguineous drainage

Which point requires correction regarding the use of restraints?

A written order for restraints is not required.

The parents of an 8-year-old African American child diagnosed with sickle cell anemia are being taught pain control measures for their child. Which measure is most important to teach the parents to prevent the onset of vaso-occlusive pain?

Encourage drinking large amounts of fluids daily.

Your patient who is 6-day post-op for a recent abdominal surgery states that he heard a popping sensation after he coughed. When assessing the wound, you notice excessive serosanguinous discharge and also see loops of the bowel protruding through the previously sutured surgical site. You immediately know that this is a/an

Evisceration

Which nursing action would be best when a preoperative client verbalizes fear of postoperative pain?

Explaining the medications ordered for pain control, availability, and treatment goals

Which action by the student nurse when applying a partial rebreather mask to a patient with low oxygen saturation needs correction by the nursing instructor?

Filling the reservoir bag with oxygen after placing the mask on the patient -Should be before

The nurse has emptied the drainage from a Hemovac drain. How will the nurse re- establish the suction?

Fully compress the drain and reapply the cap

Which of the following interventions would be most appropriate for a client who has urge incontinence?

Have the client urinate on a timed schedule.

To obtain a clean-catch urine specimen from a female patient, what should the nurse teach the patient to do?

Hold the labia apart while voiding into the specimen cup.

23. The physician orders hydromorphone hydrochloride (Dilaudid) 15 mg IM for a 56-year- old woman. Side effects of this medication that the nurse should observe the patient for include-

Hypotension and respiratory depression.

The nurse has admitted a client to the postoperative unit following a bowel resection and is providing postoperative health education on coughing and deep breathing. What does the nurse explain to the client about why these actions are important?

If you continue to breathe shallowly or cough ineffectively, this can lead to atelectasis and pneumonia.

A nurse assesses the pain level of a Native American pediatric client recovering from cardiac surgery. Knowing that Native American pediatric clients may not express pain, the nurse reviews the child's pulse and blood pressure readings following analgesic administration. Which finding should indicate to the nurse that the client's pain is not well-controlled?

Increased heart rate and increased blood pressure

In completing a client's preoperative routine, the nurse finds that the informed consent is not signed. The client begins to ask more questions about the surgical procedure. What action should the nurse take next?

Inform the surgeon the informed is not signed and the client has questions about the surgery.

A female client is being discharged from the hospital to home with an indwelling urinary catheter after the surgical repair of the bladder after trauma. The nurse determines that the client understands the principles of catheter management to prevent complications if the client states to:

Keep the drainage bag lower than the level of the bladder.

A nurse is teaching a patient about the urinary system. In which order will the nurse present the structures, following the flow of urine?

Kidney, ureters, bladder, urethra

The nurse cares for a client after a thyroidectomy. The nurse would be MOST concerned if which of the following was observed?

Tension and muscle spasm of the hand when a blood pressure cuff is applied to the arm and inflated.

Which of the following indicates to the nurse a need for further teaching for a postoperative client using the incentive spirometer?

The client exhales with the spirometer in his mouth.

A client is scheduled to have surgery. The nurse should place priority on determining whether the surgeon wants which medications held in the preoperative period to assure client safety?

Warfarin

The nurse is preparing a client to administer a small-volume cleansing enema. In what position would the nurse place the client for this procedure.

Lying on the left side with the bed flat and the back of the client facing the nurse

The implementation of diagnosis-related groups (DRGs) by Medicare in 1983 affected hospitals in which way?

Medicare pays only the amount of money preassigned to a treatment for a diagnosis.

A client is to receive a second dose of oxycodone/acetaminophen (Percocet®) for postoperative incisional pain. When a nurse brings the medication to the client, the client says, "Why bring this medication again? It makes me feel sick." Which statement is the most appropriate initial nurse response?

"Describe what you feel when you say that the medication makes you feel sick."

Which assessment question should the nurse ask if stress incontinence is suspected?

"Do you experience urine leakage when you cough or sneeze?"

The nurse is caring for a patient the first day postoperative after a transurethral prostatectomy (TURP). The patient has a continuous bladder irrigation (CBI). The patient's wife asks why he has to have the CBI. Which of the following responses by the nurse is BEST?

"The CBI enables urine to keep flowing."

A client says to a nurse, "I wish my family would let me die in peace. I get so angry that my family keeps hovering over me as if I have given up. The doctor told me I have terminal lung cancer and there is no cure!" Which is the best therapeutic response by the nurse?

"You are angry because your family thinks that you have given up hope for a cure?"

The amount of oxygen that can be delivered via a nasal cannula

1-6 L/min

A nurse is using a pulse oximeter to measure the arterial oxyhemoglobin saturation (SaO2 or SpO2) of a client's arterial blood. What range is considered a normal value for SpO2?

95-100%

1. The nurse is counseling the family of a terminally ill client about palliative care. The nurse identifies which goals as being those of palliative care? Select all that apply

A) Offering a caring support system B) Providing measure focused on pain management C) Introduction of interventions that enhance the quality of life D) Expanding the focus of care to both the client and the family E) Addressing the expressed spiritual needs of the client and the family

Which statement accurately describes a characteristic of various types of wound drainage? (Select all that apply)

A. Serous drainage is composed by the clear portion of the blood and serous membrane B. Sanguineous drainage is composed by many red blood cells and looks like blood

A nurse evaluates that a client, diagnosed with obstructing left ureterolithiasis, may have passed the calculi in the urine when which outcome has been achieved?

Absence of colicky pain in the left lateral flank and groin

A nurse applies a fentanyl (Sublimaze®) transdermal patch to a client for the first time. Shortly after application, the client is experiencing pain. Which nursing action is most appropriate?

Administer a short-acting opioid analgesic.

In reviewing a physician's orders for a postoperative client who underwent gynecological surgery, which order should a nurse determine is specifically written with the intent to prevent postoperative thrombophlebitis and pulmonary embolism?

Administer enoxaparin (Lovenox®) 40 mg subcutaneously daily

A hospitalized client, experiencing chronic abdominal pain, is receiving the maximum recommended dose of fentanyl (Duragesic®) by transdermal patch and intravenous morphine sulfate for breakthrough pain. The client continues to rate the pain at a level of 8 on a scale of 0 to 10. The client agrees to include progressive relaxation techniques through guided imagery as an intervention to lessen pain. Which should be the best method for the nurse to evaluate the effectiveness of progressive relaxation in controlling the client's pain?

Ask the client to describe and rate the pain

Which intervention is most important for the nurse to implement for a male client who is experiencing urinary retention?

Assess for bladder distention

23. A client is receiving morphine sulfate by a patient-controlled analgesia (PCA) system after a left lower lobectomy 4 hours ago. The client reports moderately severe pain in the left thorax that worsens when coughing. What should the nurse do first?

Assess the pain using a pain scale and compare to the previous assessment.

A client states to a hospice nurse, "If I could live until my grandson's wedding in 2 months, then I would be ready to die." Based on this statement, the nurse should interpret that the client is in which stage of grief?

Bargaining

What best describes measurement of post-void residual (PVR)?

Bladder scan the patient immediately after voiding.

After pelvic surgery, the client reports pain in the calf. Which action should the nurse take first?

Check the client's calf for temperature, color, and size.

When assessing a client with chest trauma, the nurse notes that the client is taking small breaths at first, then bigger breaths, and then a couple of small breaths, then 10 to 20 seconds of no breaths. How should the nurse record the breathing pattern?

Cheyne-Stokes respiration

When the nurse assesses the incision of a client two days after surgery, a shiny, pink, open area is noted with the underlying bowel visible. Which of these actions should the nurse take FIRST?

Cover the open area with sterile gauze soaked in normal saline.

Your patient who is 6-day post-op for a recent abdominal surgery states that he heard a popping sensation after he coughed. When assessing the wound, you notice excessive serosanguinous discharge and an opening of the previously sutured surgical site. No abdominal contents is noted. You immediately know that this is a/an ______________?

Dehiscence

A patient has been told that cancer has metastasized (spread) throughout the entire body. A 6-month survival rate has been established. The patient refuses to accept the diagnosis and denies the conversation ever took place. Which stage of grief is the patient experiencing?

Denial

Which nursing assessment question would best indicate that an incontinent man with a history of prostate enlargement might not be emptying his bladder adequately?

Do you dribble urine constantly?

Which assessment question should the nurse ask if stress incontinence is suspected?

Do you experience urine leakage when you cough or sneeze?"

Which instruction is most important for the nurse to include when teaching a post- operative patient with limited mobility strategies to prevent venous thrombosis?

Dorsiflex and plantarflex the feet 10 times each hour.

A client with a neurological impairment experiences urinary incontinence. Which nursing action would be most helpful in assisting the client to adapt to this condition?

Establishing a toileting schedule

A 76-year-old client, hospitalized for cancer treatment, has an emergency bowel resection for a bowel obstruction. Four hours postoperatively, the client is experiencing pain. A nurse has the choice of standing postoperative pain orders or standing orders for cancer clients (protocol orders) of which all medications are listed on the client's medication administration record. Which medication should the nurse initially select to treat the client's postoperative pain?

Morphine sulfate (Duramorph®) 4 mg IVP q3-4h prn

This mask prevents the patient from rebreathing exhaled air. The reservoir bag filled with oxygen enters the mask on inspiration. Exhaled air escapes through the side vent. This mask delivers the highest concentration of oxygen.

Non-rebreather mask

A primary health care provider writes a prescription of "Restraints PRN (as needed)" for a client who has a history of violent behavior. Which action would the nurse take?

Notify the provider that PRN prescriptions for restraints are unacceptable.

An immobile postoperative client asks the nurse why it is so important to deep-breathe and cough after surgery. When formulating a response, the nurse incorporates the understanding that retained pulmonary secretions in a postoperative client can lead to which condition?

Pneumonia

Which rationale should a nurse use to explain the reason for oxygen being bubbled through a humidifier to a client receiving 4 liters of oxygen by nasal cannula?

Prevents drying of the nasal passages

A nurse evaluates that a client has achieved an expected outcome for the second postoperative day following abdominal surgery under general anesthesia. Which finding supports the nurse's conclusion?

Rates incisional pain at 4 out of 10 on a 0 to 10 rating scale 60 minutes after analgesic given

A 19-year-old college student has a Mantoux test performed at the college health clinic. The result is positive. The clinic nurse should-

Refer the student to an appropriate center for further testing.

A Jackson Pratt (JP) drain in a post surgical patient is filled with clear pink drainage that is a mix of clear fluid and blood. The nurse knows documents this drainage as-

Serosanguineous drainage

Which instruction should the nurse include in preoperative teaching for a client who will require an abdominal binder to preserve the suture line?

Sit up for coughing while splinting the incision.

A patient who is one-day post op from a hysterectomy asks why they need to use the incentive spirometer. What should the nurse respond?

The incentive spirometer helps keep your lungs well inflated and healthy, reducing the risk of respiratory illnesses like pneumonia."

As a nurse, which statement is INCORRECT regarding an informed consent signed by a patient?

The nurse is responsible for obtaining the consent for surgery

A nurse is assessing the extremities of a client who had wrist restraints applied 2 hours ago. Which assessment finding, if present, is of greatest concern?

The skin of the hand feels cool to the touch and is pale.

The nurse is providing restraint education to a group of nursing students. Which reason to use restraints is incorrect to teach?

To prevent an adult client from getting up at night when there is insufficient staffing on the unit

An oxygen delivery system is prescribed for a client with chronic obstructive pulmonary disease to deliver a precise oxygen concentration. Which oxygen delivery system would the nurse anticipate to be prescribed?

Venturi mask

A nurse is caring for a 5-year-old child from Italy. The child is crying and the interpreter is stating that the child has extreme pain. The nurse's first priority should be to:

assess the level of the child's pain using an appropriate FACES pain rating scale.

The nurse is caring for a postoperative patient. Four hours after surgery, the patient voids 200 mL of urine with a specific gravity of 1.019. The nurse should

record the time and the amount of urine.

An adolescent male with a history of spinal cord injury reports a leaking of urine at fairly regular intervals. A nurse should document in the client's plan of care a nursing diagnosis of:

reflex urinary incontinence.

The medical/surgical nurse watches a student nurse prepare a sterile field. Which of the following actions, if performed by the student nurse, requires further instruction?

the student nurses laces he sterile drape, then turns to grab a packaged set of sterile gloves from the table behind her.