Fundamentals practice

A nurse is caring for a client who is postoperative and is experiencing nausea and vomiting. The nurse should identify which of the following findings as indications that the client has fluid volume deficit? (Select all that apply.)

Cool extremities - Orthostatic hypotension - Flat neck veins

A nurse is assisting with the admission of a client who has active tuberculosis. Which of the following actions should the nurse plan to take?

Assign the client to a negative-pressure airflow room.

A nurse is using Maslow's hierarchy of needs in assisting with discharge planning for a client. Which of the following activities should the nurse recommend as the priority for this client?

Attend an exercise program

A nurse is caring for a client who is receiving continuous NG tube feedings. The nurse listens to the client's bowel sounds. Which of the following actions should the nurse take? (Click on the audio button to listen to the clip.)

Decrease the rate of the feeding

A nurse is caring for a client who is refusing medical treatment. Which of the following actions should the nurse take?

Document the client's refusal of the treatment.

A charge nurse smells smoke, enters the visitor restroom, and sees flames in the trash can. What is the sequence of actions that the nurse should take? (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)

Evacuate clients from the area is the first step. - Pull the lever on the fire alarm box is the second step. - Close the fire doors on the unit is the third step. - Use a fire extinguisher to put out the fire is the fourth step.

A client who has advanced cancer tells the nurse that they have a difficult time talking to anyone about the illness. Which of the following actions should the nurse take to encourage therapeutic communication?

Let the client know that, as their nurse, they are available and willing to listen.

A nurse is contributing to a plan of care for a client who has a new prescription for a wrist restraint. Which of the following actions should the nurse include in the plan?

Pad bony prominences on the wrist

A nurse is moving a client up in bed with the assistance of a second nurse. Which of the following actions should the nurse take?

Place feet apart with the foot nearest the head of the client's bed in front of the other foot.

A nurse is collecting data from a client who has an NG tube set to low intermittent suction. Which of the following findings indicates hypomagnesemia?

Positive Chvostek's sign

A nurse is reinforcing teaching with a client about the use of crutches. Which of the following actions by the client indicates an understanding of the teaching?

The client advances the unaffected leg first while climbing stairs.

A nurse is collecting data from an older adult client. Which of the following findings should the nurse report to the provider?

The client reports urinary incontinence.

a nurse is caring for a group of medical-surgical unit. in which of the following situations does the nurse demonstrate the ethical principle of veracity?

a client is unaware of her recent cancer diagnosis asks the nurse is she has cancer, and the nurse responds affirmatively

A nurse is caring for a client who has a prescription for a potassium supplement. The client tells the nurse that the pill is too large to swallow and refuses to take it. The nurse offers to break the pill into two smaller pieces. The nurse is demonstrating which of the following ethical principles?

beneficence

a nurse is caring for a client who has an indwelling catheter. which of the following findings indicates that the catheter requires irrigation?

bladder scan shows 525 mL of urine

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 outward

a nurse is admitting a client who has rubella. which of the following types of transmission-based precautions should the nurse initiate?

droplet

a nurse is caring for a client who requires a 24 hr urine collection. which of the following statements by the client indicates an understanding of the teaching?

i flushed what i urinated at 7 am and have saved all urine since

a nurse is caring for a client who requires consent for a surgical procedure. which of the following actions is the nurse's responsibility?

witness the client's signature on the consent form

a nurse is planning an educational program for a group of older adults at a senior living center. which of the following recommendations should the nurse include?

you should receive a pneumococcal immunization every 10 years

A nurse is reinforcing teaching about hospice care measures with the family of a client who is dying. Which of the following statements by a member of the client's family indicates an understanding of the teaching?

"We will keep her room cool to help her breathe better."

A nurse is reinforcing dietary teaching with a client who has chronic kidney disease and requires a low-potassium diet. Which of the following food choices by the client demonstrates an understanding of the teaching?

1 cup of applesauce

A nurse is reviewing the vital signs of four adult clients. Which of the following findings requires further data collection by the nurse?

A client who has a pulse rate of 110/min

A nurse is explaining ethics and values to a newly licensed nurse. The nurse should explain that allowing a client to make a decision about a treatment is an example of which of the following ethical principles?

Autonomy

A nurse is reviewing the medical record of a client who has heart failure. The nurse should identify which of the following laboratory results as an indication that the client has fluid volume excess?

BUN 8mg/dl

A nurse is reinforcing teaching with a client about smoking cessation. Which of the following should the nurse identify as the first stage of health behavior change?

Precontemplation

A charge nurse is reinforcing teaching with an assistive personnel (AP) about performing pulse oximetry. Which of the following information should the nurse include in the teaching?

Remove polish from the client's fingernail before applying the oximetry probe.

a nurse has just inserted an NG tube for a client. which of the following findings should the nurse expect to confirm correct tube placement?

an x-ray shows the end of the tube above the pylorus

a nurse is planning care for a client who has vision loss. which of the following interventions should the nurse include in the plan of care to assist the client with feeding?

arrange food in a consistent pattern on the client's plate

a nurse is preparing to transfer a client who can bear weight on lone leg from the bed to a chair. after securing a safe environment, which of the following actions should the nurse take next?

assess the client for orthostatic hypotension

a nurse is administering IV fluids to a client. when monitoring for adverse effects, which of the following assessments should the nurse identify as the priority?

auscultate lung sounds

a nurse is giving change-of-shift report about a client they admitted earlier that day who has pneumonia. which of the following pieces of information is the priority for the nurse to provide?

breath sounds

a nurse is performing a Romberg test during the physical assessment of a client. which of the following techniques should the nurse use?

have the client stand with their arms at their sides and their feet together

a nurse is reviewing a client's medication prescription that reads, "digoxin 0.25 by mouth every day." which of the following components of the prescription should the nurse verify with the provider?

medication dose

a middle adult client tells the nurse, "i feel so useless now that my children do not need me anymore." which of the following responses should the nurse make?

people in middle adulthood often find satisfaction in nurturing and guiding young people

a nurse is caring for a client who is receiving fluids through a peripheral IV catheter. which of the following findings at the IV site should the nurse identify as indicating infiltration?

skin blanching

a home health nurse is completing an admission assessment of an older adult client who has their caregiver present. which of the following findings should the nurse identify as a potential indication of elder abuse?

the caregiver insists on remaining in the room

a nurse is assessing a client who received an IV fluid bolus for dehydration. which of the following findings should the nurse identify as an indication of fluid volume excess?

distended neck veins

a nurse is preparing to administer 0.5 mL of oral single-dose liquid medication to a client. which of the following actions should the nurse take?

gently shake the container of medication prior to administration

a nurse is teaching an older adult client who is at risk for osteoporosis about beginning a program of regular physical activity. which of the following types of activity should the nurse recommend?

walking briskly

a nurse is caring for a client who has a terminal diagnosis and whose health is declining. the client request information about advance directives. which of the following responses should the nurse make?

we can talk about advance directives, and i can also give you some brochures about them

a nurse is caring for a client who is refusing a 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 blood transfusion

a nurse in a surgical suite notes documentation on a client's medical record that he has a latex allergy. in preparation for the client's procedure, which of the following precautions should the nurse take?

wrap monitoring cords with stockinette and tape them in place

a nurse in a clinic is caring for a middle adult client who states, "the doctor says that, since i am at an average risk for colon cancer, i should have a routine screening. what does this involve?" which of the following responses should the nurse make?

you should have a fecal occult blood test every year

A nurse is speaking with a client who has type 2 diabetes mellitus and a prescription for insulin. The client verbalizes anger about having to take insulin. Which of the following responses should the nurse make?

"I see that you are angry. Let's sit down and talk."

A nurse is reinforcing teaching about the use of crutches with a client who has a fractured right tibia and fibula. Which of the following statements by the client indicates an understanding of the teaching?

"I will be sure to keep the crutch tips dry."

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 measurement in mm Hg to which the nurse should inflate the cuff when obtaining blood pressure?

the one close to 120 mm Hg

a nurse enters a client's room and finds her on the floor. the client's roommate reports that the client was trying to get out of bed and fell over the side rail onto the floor. which of the following statements should the nurse document about this incident?

client found lying on floor

a nurse is assessing an adult client who has been immobile for the past 3 weeks. for which of the following findings should the nurse intervene?

erythema on pressure points

a nurse is caring for a client who has limited mobility in his lower extremities. which of the following actions should the nurse take to prevent skin breakdown?

have the client use a trapeze bar when changing position

a nurse is caring for a client who has an NG tube and is receiving intermittent feedings through an open system. which of the following actions should the nurse take first?

tell the client to keep the head of the bed elevated at least 30 degrees

a nurse is caring for a client who has terminal liver cancer. which of the following statements should the nurse identify as an indication that the client is experiencing spiritual distress?

what could i have done to deserve this illness?

a nurse is caring for a client who has tuberculosis. which of the following actions should the nurse take? select all that apply

1)place the client in a room with negative-pressure airflow 2) wear gloves when assisting the client with oral care 3) use antimicrobial sanitizer for hand hygiene

A nurse is reinforcing teaching with a client who has a partial hearing loss about how to modify the home environment. Which of the following is a priority modification that the nurse should include?

Flashing smoke alarm

A nurse is caring for a client who has a Clostridium difficile infection. Which of the following solutions should the nurse use to perform hand hygiene while caring for this client?

Mild soap

A nurse is reinforcing teaching about health promotion with a group of young adult clients. Which of the following information should the nurse include?

Young adults should receive a dental assessment every 6 months.

a nurse is caring for a client who reports difficulty falling asleep. which of the following recommendations should the nurse make?

maintain a consistent time to wake up each day

a charge nurse is observing a newly licensed nurse prepare a sterile field for a dressing change. which of the following actions by the newly licensed nurse requires intervention by the charge nurse?

the newly licensed nurse places the cap of a bottle of sterile saline solution on the sterile field

A nurse is caring for a client who has metastatic cancer and practices Catholicism. The client asks the nurse to discuss the afterlife with them. Which of the following statements by the nurse assists in meeting the client's spiritual needs?

"Tell me what the afterlife means to you."

A nurse is reinforcing teaching with a client about living wills. Which of the following client statements indicates an understanding of the teaching?

"The living will directs my medical care when I am unable to make decisions."

A nurse is caring for a client who has a terminal illness and a family member asks why the client's mouth is continually open. Which of the following responses should the nurse make?

"The reduced muscle tone has relaxed the jaw muscles."

A nurse is reinforcing preoperative teaching with a client about how to turn, cough, and deep breathe. Which of the following statements by the client indicates an understanding of the teaching?

"This can help prevent pneumonia."

A nurse is caring for a client who has recently undergone a total bilateral mastectomy. Which of the following statements by the client requires immediate action by the nurse?

"When I look at myself in the mirror, I don't know if I can go on."

A nurse is reinforcing teaching with a client about the prevention of stress injuries. Which of the following instructions should the nurse include?

"When lifting a heavy object, keep it close to your body."

A nurse is calculating the intake and output for a client over the last 8 hr. The client is receiving a continuous IV infusion at 150 mL/hr and had 4 oz of juice and 0.5 L of water. How many mL of fluid should the nurse document as the client's intake for the last 8 hr? (Round your answer to the nearest whole number.)

1820 mL

a nurse is preparing a heparin infusion for a client who was admitted to the facility with deep-vein thrombosis. the prescription reads: 25,000 units of heparin in 0.9% sodium chloride 250 mL to infuse at 800 units/hr. at what rate should the nurse set the infusion pump?

8 mL/hr

A nurse is providing wound care for a group of clients. Which of the following wounds should the nurse identify as healing by secondary intention?

A stage 3 pressure injury on the coccyx

A nurse is caring for four clients who are required to provide informed consent for treatment. The nurse should identify that which of the following clients is able to provide informed consent?

An 18-year-old client who has acute appendicitis

A nurse is caring for a postoperative client who is at risk for thrombus formation. Which of the following interventions should the nurse delegate to an assistive personnel (AP)?

Apply thromboembolic stockings.

A nurse is assisting with the plan of care for a client who has aphasia following a stroke. Which of the following interventions should the nurse use to assist the client with communication?

Ask the client close-ended questions.

A nurse is assisting with the plan of care for four clients. Which of the following tasks should the nurse assign to an assistive personnel (AP)?

Assist a client to get out of bed after a breathing treatment.

A nurse is preparing to administer an enteral feeding to a client who has an NG tube in place. Which of the following methods should the nurse use to verify correct placement of the NG tube?

Check the pH of the gastric aspirate

A nurse is contributing to the plan of care for a client who has a prescription for elastic bandages to the lower extremities. Which of the following actions should the nurse recommend for the plan of care?

Compare the client's pedal pulses bilaterally every 4 hr.

A nurse has delegated various client care tasks to the assistive personnel (AP) on the care team. Which of the following actions by the AP should the nurse identify as correct?

Donning a mask to measure the vital signs of a client who has pertussis

A nurse is caring for a client who has an indwelling urinary catheter. Which of the following actions should the nurse take to prevent urinary tract infections?

Drain urine from the tubing before ambulation

A nurse is planning care for a client who is disoriented and at risk for falls. Which of the following interventions should the nurse include? (Select all that apply.)

Ensure that the client is wearing nonskid slippers. - Place the client in a room near the nurses' station.- Reinforce teaching about how to use the call light.

A nurse is contributing to the plan of care for a client who has a positive throat culture for streptococci. Which of the following interventions should the nurse recommend to be included in the plan of care?

Ensure that the client wears a surgical mask during transportation throughout the facility.

A nurse is repositioning a client who has quadriplegia and is in the supine position. Which of the following actions should the nurse take to prevent client musculoskeletal injury?

Internally rotate the client's hips by using a trochanter roll

a nurse is planning care for a client who has tuberculosis. the nurse should use which of the following pieces of PPE when providing care for the client?

N95 respirator

A nurse is preparing to administer oxygen to a client who has heart failure and is having severe difficulty breathing. Which of the following oxygen delivery equipment should the nurse select to provide the highest concentration of oxygen to the client?

Nonrebreather mask

A nurse is reinforcing preoperative teaching with a client who speaks a different language than the nurse. Which of the following actions should the nurse take?

Provide handouts written in the client's primary language.

A nurse is preparing to collect data from a client for a health assessment. Which of the following actions should the nurse take?

Provide privacy for the client.

A nurse is preparing to transfer a client from an acute care facility to a long-term care facility. Which of the following information should the nurse plan to include in the transfer report?

Resolved health conditions

A nurse is taking notes of client information on a piece of paper while receiving report. Which of the following actions should the nurse take to dispose of the paper?

Shred the paper in a secure container.

A nurse at a long-term care facility is caring for a client who is alert. Which of the following actions should the nurse take to protect the client's privacy?

Speak with the client about their condition after visitors have left.

A nurse is caring for a client who has just died and practiced the Islamic faith. Which of the following cultural practices should the nurse expect?

The client's face should be turned toward Mecca.

A nurse is collecting data on four clients. Which of the following findings should the nurse report to the provider?

Urine output of 200 mL over 8 hr

a nurse is teaching a group of nurses about the use of essential oils for aromatherapy. the nurse should include in the teaching that this therapy might be contraindicated for which of the following clients?

a client who has asthma

a nurse is caring for a client who has decreased mobility. which of the following actions should the nurse take to decrease the client's risk of developing plantar flexion contractures?

apply an ankle-foot orthotic device to the client's feet

a nurse is performing a peripheral vascular assessment for a client. when placing the bell of the stethoscope on the client's neck, the nurse hears the following sound. the sound indicates which of the following?

narrowed arterial lumen

a nurse is reviewing protocol in preparation for suctioning secretions from a client who has a new tracheostomy. which of the following actions should the nurse plan to take?

select a suction catheter that is half the size of the lumen

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 is teaching a client whose left leg is in a cast about using crutches. which of the following statements should the nurse identify as an indication that the client understands the teaching?

when descending the stairs, i will first shift my weight to my right leg

a nurse is admitting a client who has been having frequent tonic-clonic seizures. which of the following actions should the nurse add to the client's plan of care?

wrap blankets around all four sides of the bed

A nurse is preparing to administer a topical medication to a client. Which of the following actions should the nurse take?

Compare the label of the medication container with the medication administration record three times.

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 provide to the client and his family?

1) check the cord routinely for frays or tearing 2) consider purchasing a generator for power backup 3) observe for signs of hypoxia

A nurse is preparing to palpate a client's pulse. The nurse should recognize that which of the following pulses is located on the top of the client's foot?

Dorsalis pedis

A charge nurse is discussing the responsibility of nurses carig for clients who have C. difficile. Which of the following information should the nurse include in the teaching? a) Assign the client to a room with a negative air-flow system b) Use alcohol-based hand sanitizer when leaving the clients room c) clean contaminated surfaces in the clients room with a phenol solution d) have family members wear a gown and gloves when visiting

have family members wear a gown and gloves when visiting

A nurse is assisting with the plan of care for a client who has a bacterial infection and a persistent oral temperature of 38.9° C (102° F). Which of the following interventions should the nurse include in the plan of care to treat the fever?

Administer acetaminophen

A nurse is assisting with a presentation to a group of older adults at a community center about hypothermia and hyperthermia. Which of the following information should the nurse include about age-related changes?

Circulation becomes less efficient with age.

a nurse manager is overseeing the care activities on a unit. for which of the following situations should the nurse manager intervene due to a violation of HIPAA guidelines?

a nurse asks a nurse from another unit to assist with documentation for a client

A nurse on a medical unit is preparing to discharge a client to home. Which of the following actions should the nurse take as part of the medication reconciliation process?

compare prescriptions with medications the client received while are the facility

a nurse in an acute care facility is preparing a discharge summary for a client who is transferring to a long-term care facility. which of the following documentation should the nurse include?

current medications

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

0.3 mg

a nurse is caring for a client who has a prescription for 5 units of regular insulin and 10 units of NPH insulin to mix together and administer subcutaneously. determine the correct order of steps for this procedure

1) inject 10 units of air into the bottle of NPH insulin 2) inject 5 units of air into the bottle of regular insulin 3) withdraw the correct dose of regular insulin from the bottle 4) withdraw the correct dose of NPH insulin from the bottle

A nurse is planning to perform wound irrigation for a client who has a large abdominal wound. Which of the following actions should the nurse plan to take?

Administer an analgesic 30 min before starting the procedure.

A nurse is preparing to remove a client's peripheral IV catheter. After performing hand hygiene and applying clean gloves, which of the following actions should the nurse take first?

Clamp the infusion tubing.

a community health nurse is checking blood pressures for a group of clients at a community health screening. which of the following clients is at an increased risk for hypertension?

a client who smokes one pack of cigarettes each day

a nurse is caring for a client who is receiving pain medication through a patient-controlled analgesia pump. which of the following actions should the nurse take?

instruct the family to refrain from pushing the button for the client while she is asleep

a nurse is planning on teaching for a group of adolescents who each recently had surgical placement of an ostomy. which of the following methods should the nurse use as a pyschomotor approach to learning?

practice sessions

a nurse is discussing the use of herbal supplements for health promotion with a client. which of the following client statements indicates an understanding of herbal supplement use?

i can take echinacea to improve my immune system

a nurse is caring for a client who has recently started using a behind the ear hearing aid. which of the following statements should the nurse identify as an indication that the client understands the use of this assistive device?

i will be sure to remove my hearing aid before taking a shower

a nurse is reviewing practice guidelines with a group of newly licensed nurses. which of the following interventions should the nurse include that is within the RN scope of practice?

initiate an enteral feeding through a gastrostomy tube

A nurse is assisting with the admission of a client who has brought their medications to the facility. Which of the following actions should the nurse take?

Compare the medications the provider has prescribed with the client's medications from home.

a nurse is preparing to delegate client care tasks to an assistive personnel. which of the following tasks should the nurse delegate?

ambulating a client who is postoperative

A nurse is calculating a client's fluid intake over the past 8 hr. Which of the following should the nurse plan to document on the client's intake and output record as 120 mL of fluid?

8 oz of ice chips

A nurse is assisting with the care of a recently deceased client. Which of the following actions should the nurse complete prior to the family viewing the body?

Clean soiled areas of the body.

A client who is nonambulatory notifies the nurse that his trash can is on fire. After the nurse confirms the fire, which of the following actions should the nurse take next?

evacuate the client

a nurse is preparing to administer multiple medications to a client who has an enteral feeding tube. which of the following actions should the nurse plan to take?

flush the tube with 15 mL of sterile water

a nurse is completing an admission assessment for a client who reports vomiting and diarrhea for the past 3 days. which of the following findings should the nurse expect?

rapid heart rate