Fundamentals of Nursing Set II

A client is receiving oxygen therapy by venturi-mask to deliver a FiO2 of 65%. The client is distressed by having the mask in place and asks if he can have the little nose things he had once before. The best nursing response would be: A. "i'll call the doctor and get an order to change. It should not make a difference." B. "The prongs that provide oxygen below your nose cannot provide this amount of oxygen. What can I do to make you more comfortable with the mask?" C. "We can change to them if you prefer." D. " Try to tough it out. If you really cannot stand it, maybe the doctor will do something else when he comes in."

B. "The prongs that provide oxygen below your nose cannot provide this amount of oxygen. What can I do to make you more comfortable with the mask?"

A nurse need to administer an intradermal tuberculin skin test injection to a client. What is the most suitable angle when administering an intradermal injection? A. 45 degree angle B. 10 degree angle C. 180 degree angle D. 90 degree angle

B. 10 degree angle

A man is diagnosed with terminal kidney failure. His wife demonstrates loss and grief behaviors. What type of loss is the wife experiencing? A. Toast B. Anticipatory loss C. Bereavement D. Maturational loss E. Dysfunctional grieving

B. Anticipatory loss

The nurse is assessing the smoking history of a 62 year old man. The man states that he smoked a pack of cigarettes for 32 years. How many pack years does the nurse document for this client? A. 42 pack years B. 50 pack years C. 30 pack years D. 32 pack years

D. 32 pack years

The client is a minor child who was involved in an accident. The child is now on a pediatric unit. The health care provider has prescribed the client to receive 2 units of packed red blood cells due to a low hemoglobin and hematocrit.The nurse needs to obtain consent from a parent to initiate the blood therapy. The client's religion is Jehovah's Witnesses. What is the nurse's first action? A. Contact the ethics board at the clinical agency about this situation. B. Administer the blood without obtaining consent. C. Notify the health care provider that the client is a member of Jehovah's Witnesses. D. Ask the parent to consent for administration of the blood.

D. Ask the parent to consent for administration of the blood.

Which two blood tests are most important in assessing kidney function? A. CBC and hematocrit B. BUN and hematocrit C. CBC and creatinine D. BUN and creatinine

D. BUN and creatinine

When a blood pressure cuff is too narrow for an individual's arm, the blood pressure is: A. Not affected B. Normal C. Falsely low D. Falsely high

D. Falsely high

Which one of the following is the cause of ascites? A. Flatus B. Feces C. Fibroid tumor D. Fluid

D. Fluid

Mr. Brown has a severe large pressure ulcer that the hospital staff is working to heal. What type of diet would best meet the needs of the client? A. Diabetic diet B. Renal diet C. Protein-restricted diet D. High-calorie, high-protein diet E. Full liquid diet

D. High-calorie, high-protein diet

Which of the following links in the infection chain is the basis for the type of isolation implemented? A. Strict isolation B. Infectious agent C. Respiratory link D. Means/mode of transmission

D. Means/mode of transmission

You and an unlicensed assistive personnel are preparing to turn an immobile client from her back to her right side. Which of the following actions will you take first? A. Place a pillow between her knees and ankles B. Cross the patient's left leg over her right leg C. Externally rotate the patient's right shoulder D. Move the patient to the left side of the bed

D. Move the patient to the left side of the bed

A nurse is ambulation a client who has had a stroke. The client has weakness on the right side of the upper body. Where would the nurse stand to walk the client? A. In back of the patient B. In front of the patient C. On the strong side D. On the weak side

D. On the weak side

A client with dehydration is being administered IV fluids. During rounds, the nurse noticed that the skin immediately surrounding the IV site was reddish in color and showing signs of inflammation. The nurse recognizes that what phenomenon is likely responsible? A. Infiltration B. Thrombus formation C. Pulmonary embolus D. Phlebitis

D. Phlebitis

A nurse is teaching a home care client how to do pursed-lip breathing. What is the therapeutic effect of this procedure? A. Replacing the use of incentive spirometry B. Using upper chest muscles more effectively C. Reducing the need to PRN pain medications D. Prolonging expiration to reduce airway resistance

D. Prolonging expiration to reduce airway resistance

A nurse developing a plan of care for a client newly admitted with prolonged diarrhea establishes which of the following as the priority diagnosis for the client? A.Risk for impaired skin integrity related to prolonged diarrhea B. Anxiety related to lack of control of fecal elimination C. Knowledge deficit related to lack of previous experience D. Risk of fluid volume deficit related to prolonged diarrhea

D. Risk of fluid volume deficit related to prolonged diarrhea

You are administering an enema to a female client who is constipated. You notice the client's skin is pale and a little moist. You take the pulse and obtain a rate of 44 bpm. What do you suspect is occuring? A. She is hemorrhaging internally. B. This is a normal reaction to an enema when one is so full of feces. C. She has a fecal impaction. D. She is having a vagal response.

D. She is having a vagal response.

The nurse is assessing a client's respiratory status. The client's breathing is rapid and shallow at a rate of 28 breaths per minute. What is the appropriate term for this client's respiratory status? A. Orthopnea B. Tachycardia C. Bradypnea D. Tachypnea E. Apnea

D. Tachypnea

How will you know if your client teaching about using the incentive spirometer was effective? A. The patient will verbalize that the spirometer will help prevent blood clots in his/her lungs. B. The patient will change the settings on the spirometer to a lower number each day. C. The patient will blow forcefully into the spirometer 10 times each hour. D. The patient will demonstrate the correct use of inspiration into the spirometer and correctly answer questions about how and why to use a spirometer.

D. The patient will demonstrate the correct use of inspiration into the spirometer and correctly answer questions about how and why to use a spirometer.

A dyig client is undergoing terminal weaning. What is the purpose of this intervention? A. To manage the symptoms of the illness. B. To initiate life-sustaining measures for the client. C. To prepare for resuscitation of the client. D. To gradually withdraw mechanical ventilation.

D. To gradually withdraw mechanical ventilation.

Changes seen in the pulmonary system as a result of immobility include increased pooling of secretions and mucus in the lungs which can cause: A. Orthostatic hypotension B. Venous stasis C. Hypostatic pneumonia D. Disuse tuberculosis

C. Hypostatic pneumonia

Diets modified by consistency include all of the following except: A. Clear liquid diet B. Mechanical soft diet C. Low-sodium diet D. Pureed diet

C. Low-sodium diet

While assessing the skin of a client on bedrest, you notice an undocumented area of non-blanchable erythema over the left hip with a small blister in the center. What action will you take? A. Massage the are vigorously with lotion to promote circulation B. Order a special gel-filled mattress for the patient C. Notify the physician that a possible pressure ulcer has developed

C. Notify the physician that a possible pressure ulcer has developed

What type of order would a physician most likely write to treat a client whose pain levels vary widely throughout the day? A. One-time B. Stat C. PRN D. Standing

C. PRN

A client is diagnosed with a terminal illness. Who is usually responsible for deciding what, when, and how the client should be told? A. Family B. Chaplain C. Physician D. Nurse

C. Physician

A camp nurse is educating a group of adolescent girls on the importance of regular physical exercise. Which level of preventive care does this activity represent? A. Restorative B. Tertiary C. Primary D. Secondary

C. Primary

Order: Levothyroxine 500 mcg p.o. tid Available: Levothyroxine 0.5 mg per tablet Per dose- Administer ____________________

1 tab

The nurse works on a med-surg unit and is beginning assessments for clients. Which client would the nurse assess first, based on recent vital sign readings? A. The client whose axillary temperature is 98.5* F B. The client whose blood pressure is 102/62 mmHg C. The client whose respiratory rate is 9 breaths/minute D. The client whose radial pulse is 100 beats/minute

C. The client whose respiratory rate is 9 breaths/minute

Your client's weight is 22 pounds. To record your client's weight in kg, you would record your client's weight as:

10 kg

Order: Procrit 9,750 units subcutaneous every 8 hours Available: Procrit 4,000 U/mL Administer: ______________

2.4 mL

Your client's temperature has been recorded as 100.2* F. The policy requires all temperatures to be recorded in Celsius. What is your client's temperature converted to in Celsius?

37.9* C

A client has been recently diagnosed with diabetes. He is seen in the emergency room every day with high blood sugar. The client apologizes to the nurses for bothering them every day but he cannot give himself insulin injections. What should the nurse's response be? A. "Has someone taught you how to take them?" B. "You could ask the doctor to change the medication." C. "You should learn to take injections yourself." D. "I myself cannot take insulin injections."

A. "Has someone taught you how to take them?"

Kübler-Ross defines five stages of psychosocial responses to dying and death. Which statement is characteristic of the bargaining stage? A. "Just let me live to see my grandson born." B. "I've had a good life and I can die in peace." C. "The doctors must have made a mistake." D. "Why did this happen to me? I always exercised."

A. "Just let me live to see my grandson born."

A client says to the nurse, "That night nurse need to go back to school. She gave me a shot in the wrong arm, she forgot to fill my water pitcher, and she wouldn't answer my light!" What would be a therapeutic response by the nurse? A. "Sounds like you had a bad night. Tell me more about it, and let's see if there is anything I can do to help you now." B. "Well the least competent nurses do sort of drift to the night shift. I don't blame you for being upset." C. "You seem fine this morning. I guess it couldn't have been that bad." D. "We are always understaffed on nights. I'm sure the nurse did the best she could."

A. "Sounds like you had a bad night. Tell me more about it, and let's see if there is anything I can do to help you now."

Critical thinking is an essential component in all phases of the nursing process. What question might be used to facilitate critical thinking during outcome identification and planning? A. "What problems require my immediate attention or that of the team?" B. "How do I document care accurately and legally?" C. "What major defining characteristics are present for a nursing diagnosis?" D. "How do I best cluster these data and cues to identify problems?"

A. "What problems require my immediate attention or that of the team?"

The client reports taking an OTC laxative daily for several weeks and remains constipated. What are appropriate actions of the nurse? Select all that apply. A. Assess the client's diet and fluid intake. B. Instruct the client to continue taking bisacodyl until the medication produces a bowel movement. C. Ask the client about abdominal pain. D. Tell the client to increase fiber intake and keep fluid intake the same. E. Question the client about the color, consistency, pattern, and shape of stools. F. Auscultate the abdomen for bowel sounds.

A. Assess the client's diet and fluid intake. C. Ask the client about abdominal pain. E. Question the client about the color, consistency, pattern, and shape of stools. F. Auscultate the abdomen for bowel sounds.

A client visits the health care facility for a scheduled physical assessment. What should the nurse do when physically assessing the quality of the client's oxygenation? Select all that apply. A. Check the symmetry of the client's chest. B. Observe the breathing pattern and effort. C. Monitor the client's respiratory rate. D. Note the amount of urine output in a 24 hour period.

A. Check the symmetry of the client's chest. B. Observe the breathing pattern and effort. C. Monitor the client's respiratory rate.

A client is admitted to the hospital with abrupt symptoms of increasing shortness of breath, fever, and a productive cough with green sputum. Upon further exam, the client is diagnosed with chronic obstructive pulmonary disease (COPD) exacerbation. The nurse identifies this as which type of illness? A. Chronic B. Acute C. Contagious D. Terminal

A. Chronis

When a person has a fever or diaphoresis, the urine output will be: A. Decrease B. Increase

A. Decrease

You are instructing your patient on collecting all urine passed in a 24-hour period. One of the most important steps in obtaining a 24-hour urine sample is to: A. Have the patient void, discard this urine, note the time, and then begin collecting. B. Keep the sample of room temperature. C. Begin the collection time as soon as the doctor orders the test. D. Make sure there is a preservative in the collection bottle.

A. Have the patient void, discard this urine, note the time, and then begin collecting.

According to Maslow, which of the following needs is the most important to fulfill? A. The need for acceptance B. The need for love because this is the most important need a human being ever experienced. C. The need for rest because it is on the 1st level of hierarchy and is therefore most basic. D. The need for self-actualization because it is the highest need.

C. The need for rest because it is on the 1st level of hierarchy and is therefore most basic.

What nursing diagnosis has the highest priority? A. Ineffective airway clearance related to incisional pain B. Social isolation related to impaired mobility C. Impaired skin integrity related to leakage of ileostomy drainage D. Anxiety related to outcome of diagnostic bronchoscopy

A. Ineffective airway clearance related to incisional pain

You are caring for a client who is hospitalized with congestive heart failure and is retaining fluids. Which of the following therapeutic diets is most likely to be ordered for this client? A. Low-sodium diet B. Calorie-restricted diet C. High-protein diet D. Clear liquid diet

A. Low-sodium diet

The nurse is a new graduate and is starting her first job. The nurse wants to project an image of a healing presence to the clients. Which actions would the nurse employ to project a healing presence? Select all that apply. A. Maintain privacy for clients when providing nursing care. B. Seek ways to set appropriate boundaries with clients and with others in the workplace. C. Encourage client to adhere to the health care provider's recommendations even when the client wants something different. D. Develop a group of friends that can provide the nurse with support E. Remain calm even in situations that are stressful.

A. Maintain privacy for clients when providing nursing care. B. Seek ways to set appropriate boundaries with clients and with others in the workplace. D. Develop a group of friends that can provide the nurse with support E. Remain calm even in situations that are stressful.

The largest amount of cooling of the body occurs through the movement of heart from a warmer source to a cooler source throughout the air around us. An example of this would be a client who is uncovered in a room that has a low temperature. This mechanism of cooling is called: A. Radiation B. Conduction C. Evaporation D. Convection

A. Radiation

Factors that are known to cause diarrhea include: Select all that apply. A. Stress B. Depression C. The natural again process D. Recent change in diet

A. Stress D. Recent change in diet

Which are correctly written as client goals? Select all that apply. A. The client will rate pain as a 3 or less on a 10-point scale by 1700 today. B. The client will eat at least 75% of all meals by May 5. C. The client will understand the side effects of digoxin. D. The client will identify five low-sodium foods by October 9. E. The client will know the signs and symptoms of infection.

A. The client will rate pain as a 3 or less on a 10-point scale by 1700 today. B. The client will eat at least 75% of all meals by May 5. D. The client will identify five low-sodium foods by October 9.

A client has a black, hard, leathery scab on his left heel. The stage of this ulcer is: A. Unstageable B. Stage II C. Deep tissue injury D. Stage III

A. Unstageable

A nurse is teaching a home care client and the family about using prescribed oxygen. What is a critical factor that must be included in teaching? A. The cost and source of supply for the oxygen B. The importance of communication with the client C. The safety measures necessary to prevent a fire D. The need to provide good skin care

C. The safety measures necessary to prevent a fire

The client's expected outcome is "The client will maintain skin integrity by discharge." Which measure is best in evaluating the outcome? A. The client's ability to reposition self in bed B. Pressure-relieving mattress on the bed C. Condition of skin over bony prominence D. Percent intake of a diet high in protein

C. Condition of skin over bony prominence

A female client is on isolation because she acquired a methicillin-resistant Staphylococcus aureus (MRSA) infection after hospitalization for hip replacement surgery. What name is given to this type of infection? A. Antimicrobial B. Viral C. Healthcare-associated (HAI) D. Iatrogenic

C. Healthcare-associated (HAI)

The client is actively dying and has a prescription for Do Not Resuscitate. The nonresponsive client is mouth breathing and has noisy respirations. The client is incontinent of uring and feces. Family is at the bedside. What interventions would be appropriate for the nurse to perform to meet the needs of the client and family? Select all that apply. A. Provide ice chips for the family to administer to the client B. Cleanse the client's mouth every shift and PRN. C. Elevate the head of the bed to a semi-Fowler's position. D. Insert a catheter for the client's urinary incontinence. E. Encourage the family to reminisce about positive, enjoyable events that the client and family shared together

B. Cleanse the client's mouth every shift and PRN. C. Elevate the head of the bed to a semi-Fowler's position. E. Encourage the family to reminisce about positive, enjoyable events that the client and family shared together

The nurse is caring for a client with a diagnosis of end-stage renal disease. The client has expressed the desire to be "kept comfortable" and to not continue further treatment. The daughter arrives from out of town and is demanding to have further testing done to determine the best treatment option for the client. What is the best action for the nurse to take at this time? A. Persuade the client to agree to the daughter's request B. Explain to the daughter the wishes of the client. C. Arrange a meeting between the physician and daughter to change code status. D. Contact the imaging center to schedule the testing.

B. Explain to the daughter the wishes of the client.

The post-abdominal-surgical client is noted by the nurse to have shallow respirations of 8 per minute and tachycardia. The nurse obtains an order for oxygen administration as the client is at risk for: A. Orthopnea B. Hypoventilation C. Hyperventilation D. Airway Obstruction

B. Hypoventilation

The client has an order to have oxygen administered by nasal cannula to keep the O2 saturation at 90% or greater. The oxygen is currently at 1 L per minute with a saturation of 85%. The nurse should: A. Leave the flow rate set as is because 85% is close enough for this test. B. Increase the flow rate to 2 liters per minute. C. Notify the physician because any higher level of oxygen is dangerous. D. Decrease the flow rate.

B. Increase the flow rate to 2 liters per minute.

In planning to meet the nutritional needs of a critically ill client in the intensive care unit, which factor will increase the client's basal metabolic rate? A. Advanced age B. Infection C. Prolonged fasting D. Long periods of sleep

B. Infection

The nurse is assessing factors related to a client's complaint of constipation. Which of the following factors are associated with constipation? Select all that apply. A. Increased intake of coffee B. Insufficient activity of immobility C. Change in diet D. Insufficient fluid intake

B. Insufficient activity of immobility C. Change in diet D. Insufficient fluid intake

The elevation of the WBC count noted on your client with a diagnosis of urinary tract infection is called: A. Neutrophils B. Leukocytosis C. Polycythemia D. Differential

B. Leukocytosis

Your client with a diagnosis of paraplegia has a fecal impaction. Which of the following types of enemas should be given, initially, to soften stool before an attempted digital removal? A. High-cleansing B. Oil retention C. Soap suds D. Low-cleansing

B. Oil retention

The nurse is educating a client on the proper procedure for a stool test for occult blood. The nurse should caution the client to omit which food from her diet? A. Eggs B. Red meat C. Dairy products D. Green vegetables

B. Red meat

A client verbalizes to a mental health counselor that his life is meaningless since his wife divorced him and that he no longer wants to live. What nursing diagnosis, resulting from his spiritual distress, would be appropriate? A. Powerlessness B. Risk for Self-Directed Violence C. Fear D. Sexual Dysfunction

B. Risk for Self-Directed Violence

Your client has just returned to his room after undergoing exploratory abdominal surgery. You note red drainage saturated on his dressing. You will describe the drainage as which one of the following: A. Serous-sanguineous B. Sanguineous C. Purulent D. Serous

B. Sanguineous

You are caring for a 78 year old female client who lives alone. She was admitted to the hospital with malnutrition and anemia. You are suspicious that she has a fecal impaction based on the fact that: A. She tells you that she only has a bowel movement every other day. B. She has been incontinent of continuous small amounts of liquid stool all times today. C. Her last bowel movement was yesterday. D. Her bowel sounds are hyperactive in all four quadrants of her abdomen.

B. She has been incontinent of continuous small amounts of liquid stool all times today.

Pulse pressure is: A. The radial pulse minus the apical pulse B. The difference between the systolic pressure and the diastolic pressure C. The pressure of blood as it circulates in the arteries D. The blood pressure minus the pulse

B. The difference between the systolic pressure and the diastolic pressure

A client taking insulin has his levels adjusted to ensure that the concentration of drug in the blood serum produces the desired effect without causing toxicity. What is the term for this desired effect? A. Peak level B. Therapeutic range C. Trough level D. Half-life

B. Therapeutic range

Discharge planning should begin: A. When the client is well B. Upon admission C. The day before discharge D. 24 hours after admission

B. Upon admission

When a client with a repair of a fractured hip has gained stability and is ready to progress to the use of a cane, following use of a walker, you would teach the client to: A. Hold the cane on the affected side B. Hold the cane in front of the patient so that this provides support for both extremities. C. Hold the cane on the unaffected side. D. Hold the cane in the dominate hand regardless of the side that was injured.

C. Hold the cane on the unaffected side.

You are delegating a task for monitoring the output of an elderly male client at risk for oliguria. He has an indwelling catheter in place. Which is the most appropriate direction for you to give an unlicensed assistant? A. "Tell me is his urine output decreases." B. "Check his output half-way through the shift and let me know the total." C. "Check his output after 2 hours. If it is not above 60 mL let me know immediately." D. "Keep an eye on his output for me."

C. "Check his output after 2 hours. If it is not above 60 mL let me know immediately."

The nurse realizes that the patient with a shoulder incision needs more teaching when the client says: A. "I know how to change the dressing on my incision and have done it three times." B. "If my fever goes about 101 degrees, I will notify my doctor." C. "I will take the antibiotics until the doctor removes the staples." D. I know the signs of infection and will report them to the physician if they occur."

C. "I will take the antibiotics until the doctor removes the staples."

A nurse is preparing a client for a physical assessment. The client appears anxious about the assessment. Which statement by the nurse would be most appropriate? A. "Some of the examination may be painful but I will be gentle." B. "I have to do this, so just relax and it won't last long." C. "Let me tell you what I will be doing. It should not be painful." D. "This is nothing to worry about. None of this will hurt you."

C. "Let me tell you what I will be doing. It should not be painful."

How much fluid should the average adult take in each day? A. 500 to 1,500 mL B. 500 to 1,000 mL C. 2,000 to 3,000 mL D. 3,000 to 4,000 mL E. 500 mL or less

C. 2,000 to 3,000 mL

When taking an initial blood pressure, the cuff should be inflated to ___ mmHg above the client's highest systolic pressure. A. 10 B. 80 C. 30 D. 100

C. 30

If a client had a stage III pressure ulcer, you would expect to see which of the following assessment? A. An open area that reveals damage to the epidermis, dermis, subcutaneous tissue, muscle, fascia, tendon, capsule, and bone. B. Erythema that remains 15-30 minutes after the pressure is relieved and does not blanch. C. An open area that extends through the epidermis, dermis, and subcutaneous tissue with possible undermining and tunneling D. Intact serum-filled blisters and broke blisters with shallow, pink or red shiny ulcerations

C. An open area that extends through the epidermis, dermis, and subcutaneous tissue with possible undermining and tunneling

When caring for your 52 year old client you note that he is having difficulty breathing. He is lying in bed and is already receiving oxygen therapy via nasal cannula. Which of the following interventions would the nurse do first? A. Promote removal of pulmonary secretions B. Obtain a specimen for atrial blood gases C. Assist the patient to Fowler's position D. Increase the oxygen flow

C. Assist the patient to Fowler's position

A nurse is assessing a client the first day after colon surgery. Based on knowledge of the effects of anesthesia and manipulation of of the bowel during surgery, which focused assessment will be included? A. Urinary output B. Pulse amplitude C. Bowel sounds D. Skin turgor

C. Bowel sounds

You are working the 11:00 pm to 7:00 am shift. Your client is a new post-op admission following cranial surgery. He is nauseated and vomits 375 mL of yellow liquid at 1:00 am. At 2:00 am he vomits another 125 mL of liquid. You give him some medication and he falls asleep and rests well . He has continuous IV fluids infusing at 100 mL/hr. You empty his catheter bag and note 1450 mL of clear yellow urine. Calculate the intake and output for your shift.

Intake: 800 mL Output: 1950 mL