Fundamentals Pretest Practice

A nurse is caring for a client who is 1 day postoperative following gynecologic surgery and reports incisional pain. Which of the following actions should the nurse take first?

Ask the client to rate her pain on a scale from 0 to 10.

A nurse is assessing a client's cranial nerves. Which of the following methods should the nurse use to assess cranial nerve II?

Ask the client to read a Snellen chart

A nurse is assessing a client's abdomen who reports stomach pain. Which of the following actions should the nurse take first?

Inspect

A nurse working in a community health center is preparing a flow sheet detailing essential screenings according to age group. At which developmental stage on the chart should the nurse add scoliosis screening?

Pre-adolescent/adolescent

A nurse is auscultating the breath sounds of a client who has asthma. When the client exhales, the nurse hears continuous high-pitched squeaking sounds. The nurse should document this as which of the following adventitious breath sounds?

Wheezes

A nurse is assissting an older adult client who sometimes loses her balance while walking. Which of the following devices should the nurse use when helping the client ambulate?

gait belt

A nurse is assessing a client who has insomnia. Which of the following questions is the highest priority for the nurse to ask the client?

"Do you have difficulty staying awake when you are driving?"

A nurse is preparing to perform hand hygiene. Which of the following actions should the nurse take?

Apply 4 to 5 mL of liquid soap to the hands

A nurse is caring for a client who requires cold applications with an ice bag to reduce the swelling and pain of an ankle injury. Which of the following actions should the nurse take?

Apply the bag for 30 min at a time

A nurse is assessing a client's circulatory system. Which of the following pulse sites should the nurse avoid assessing bilaterally at the same time?

Carotid

A nurse is caring for a client who is about to have a colonoscopy. The client states, "I am so nervous about what the doctor might find during the test." The nurse ask the client, "Are you feeling anxious about the results of your colonoscopy?" With this question, the nurse is using which of the following communication techniques?

Clarification

A nurse is giving change-of-shift report using SBAR to the oncoming nurse on a client who has a traumatic brain injury. Which of the following information should the nurse include in the background segment of SBAR?

Code status

A nurse observes an adolescent client who has paraplegia sitting in a wheelchair crying. The client says, "Go away; no one can help me." Which of the following responses should the nurse make?

"I will come back later and we can talk."

A client states, "why do I feel relief now that my dad is gone?" Which of the following responses should the nurse make?

"Tell me what you are thinking."

A nurse is caring for a client who has fallen while getting out of bed and states, "I'm okay! I guess I should have called for help to the bathroom." After assessing the client, the nurse notifies the provider. Which of the following documentation should the nurse include in the client's medical record?

"The provider was notified."

A nurse is providing preoperative teaching for a client who will undergo surgery. The nurse explains that the client will wear antiembolism stocking during and after the procedure. When the client asks what the stockings do, which of the following responses should the nurse make?

"They improve your circulation to keep blood from pooling in your leg."

A nurse is preparing to collect health history data during a client's admission. Which of the following questions should the nurse use to promote this discussion?

"What brought you to the hospital?"

A nurse is caring for a client whose partner ask to speak with the nurse. The partner relates her concerns about her spouse abusing alcohol and having difficulty maintaining employment. Which of the following responses should the nurse make?

"What have you done in the past to cope with this issue?"

A nurse at an extended-care facility is instructing a class of assitive personnel (AP) about client use of assistive devices during ambulation. Which of the following instructions should the nurse give the APs about the clients' use of a cane?

"When the client moves, he should move the cane forward first."

A nurse is assisting with the admission of a client who is about to have elective surgery. The client tells the nurse she feels anxious. Which of the following responses should the nurse make?

"tell me more about your concerns."

A nurse is caring for a client within the intimate zone of the client's personal space. The nurse should perform which of the following activities in this space? (select all that apply.)

-Auscultating heart sounds -Changing a dressing

A nurse is assessing a client who is experiencing complications due to immobility. Which of the following findings should the nurse expect? (select all that apply.)

-Contractures of the extremities -Crackles in the lungs -Pressure ulcers

A nurse is documenting in a client's medical record. Which of the following abbreviations is appropriate for the nurse to use? (select all that apply)

-bid -30 mL

A nurse is reviewing a client's prescription for 1,000 mL of 5% dextrose in water IV to infuse over 8 hr. At 1400, the nurse observes that there is 500 mL of solution remaining in the client's current IV bag. At what time should the nurse administer the next bag of IV solution?

1800

A nurse is caring for a client who has a mental health disorder. The client asks about his medications and their effects. The nurse asks the client why he needs to know this. Which of the following nontherapeutic communication techniques is the nurse using?

Asking for an explanation

A nurse is applying a cold compress for a client who has pain and minor swelling in a sutured laceration on the forearm. Which of the following assessments should the nurse use to determine whether the treatment is effective?

Asking the client to rate the pain

A nurse is teaching a client who has strained her back muscles while preparing to move to a new apartment. Which of the following instructions should the nurse include?

Bend at the knees when picking up an object

A nurse is having difficulty reading the provider's writing when transcribing a prescription for a client's medication. Which of the following actions should the nurse take?

Contact the provider to clarify the prescription

When reviewing the admitting prescriptions for a client, the nurse notes that the dose of one medication is three times the usual dose of this medication. Which of the following actions should the nurse take?

Contact the provider to question the dosage

A nurse is planning care for a client who has a decreased level of consciousness. The client is receiving continuous enteral feedings via a gastrostomy tube due to an inability to swallow. Which of the following is the priority action by the nurse?

Elevate the head of the client's bed 30 degree to 45 degree

A nurse is caring for a client who reports difficulty sleeping while in the hospital. Which of the following actions taken by the assistive personnel (AP) while the client is sleeping should prompt the nurse to intervene?

Flushes the client's toilet after emptying the urinary catheter's drainage bag

A nurse is assisting with transferring a client from the bed to a wheelchair. Which of the following actions should the nurse take?

Lock the wheels of the bed and the wheelchair

A nurse is assessing a client's bowel sounds. At which of the following points in the assessment should the nurse auscultate the client's abdomen?

Prior to percussing the abdomen

A nurse in a long-term care facility enters the day room and finds the window curtains on fire. Clients are panicking and the room is filling with smoke. Indicate the emergency actions the nurse must take. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

RACE 1) Remove the clients from the room 2) Activate the fire alarm 3) Close the door 4) Extinguish the fire

A nurse is an urgent care center is caring for a client who experienced an ankle injury. Prior to examination by the provider. Which of the following nursing actions should the nurse perform? (Select all that apply.)

RICE - Rest, Ice, Elevate, Compression -Apply ice to affected area -Apply a compression bandage -Elevate the foot

A nurse is caring for a client who is discussing his post-traumatic stress disorder and states: "Everyone thinks you should be able to put it out of your mind. It happened so long ago - just get over it!" The nurse responds. "It must be very frustrating to encounter this kind of attitude." The nurse is using which of the following therapeutic communication techniques?

Reflection

A newly licensed nurse is applying prescribed wrist restraints on a client. Which of the following actions should the nurse take?

Secure the restraints using a quick-release tie

A nurse is performing a pain assessment for a client who is alert. The nurse should recognize that which of the following measures is the most reliable indicator of pain?

Self-report of pain

A nurse is caring for a client who is receiving heat applications using an aquathermia pad. Which of the following actions should the nurse take when applying the pad?

Stop the treatment if the client's skin becomes red.

A nurse is assessing a client's cardiovascular system. To palpate for unexpected pulsations in the pulmonic area, at which anatomical location should the nurse place her fingers?

The left second intercostal space

A nurse is caring for an older adult client who has a fractured hip and will require rehabilitative care. The client's family asks the nurse for information about this type of care. Which of the following explanations should the nurse provide?

The service began with the client's admission to the hospital

A nurse on a medical unit is teaching a group of assistive personnel about handling clients' bed linens safely. Which of the following instructions should the nurse include?

Tie linen bags securely at the top

A nurse is using the communication principle of presence when establishing a collaborative relationship with a client. Which of the following actions should the nurse take?

Use attentive listening with the client

A nurse is completing the initial admission assessment and history for a client. Which of the following is the priority action for the nurse to take?

Document the client's allergies in the electronic medical record

A nurse is reviewing the goals of the nurse-client therapeutic relationship with a client who is seeking counseling. Which of the following information should the nurse include in this discussion?

The client achieves optimal personal growth

A nurse is caring for a client who is postoperative following a cholecystectomy and reports pain. Which of the following actions should the nurse take? (Select all that apply.)

-offer the client a back rub -remind the client to use incisional splinting -identify the client's pain level -Change the client's position

A nurse is monitoring a client who is postoperative and unable to respond to questions. Which of the following nonverbal behaviors should the nurse identify as an indication that the client has pain? (select all that apply.)

-restlessness -grimacing -clenching

A nurse is developing a therapeutic relationship with a client. The nurse should perform which of the following actions during the working phase of a therapeutic relationship?

Instruct the client about methods to achieve goals

A nurse is orienting a newly licensed nurse about documentation of a client's information in the electronic health record. Which of the following statements by the newly licensed nurse indicates understanding of the purpose of documentation?

"Documentation is a communication tool for the interprofessional health care team."

A nurse is caring for a client who has an electrical burn. With the client's permission, the nurse is answering questions from the family about his status. Which of the following responses should the nurse make?

"He has an electrical burn. He is stable, and we will update you with any changes."

A nurse is teaching a client about carbon monoxide poisoning. Which of the following statements should the nurse identify as an indication that the client needs further instruction?

"I can detect the presence of carbon monoxide by a metallic odor."

A nurse is rehearsing assertive communication approaches to use when declining leadership of a nursing department committee. Which of the following statements should the nurse make?

"I decline the opportunity at this time."

A nurse is instructing a young adult client about healthful sleep habits. Which of the following statements should the nurse identify as an indication that the client needs further teaching?

"I watch television until I fall asleep at night."

A nurse is conducting a health promotion class for clients and their children about sun protection. The nurse should identify which of the following client responses as an indication that the teaching was effective?

"I will avoid sitting in the sun between 10 a.m. and 3 p.m."

A nurse is teaching a client about how to use her new hearing aids. Which of the following statements should the nurse identify as an indication that the client needs further instruction?

"I will clean the hearing aids with alcohol wipes."

A nurse is providing teaching to an assistive personnel (AP) about caring for clients with restraints. Which of the following statements by the AP indicates an understanding of the teaching?

"I will tie a restraint to the portion of the bed that moves when the head of the bed is moved."

A nurse is teaching a client who reports insomnia about promoting rest and sleep. Which of the following statements should the nurse identify as an indication that the client needs further teaching?

"I will walk briskly for 30 minutes before bedtime."

A nurse is reviewing information about the Health Insurance Portability and Accountability Act (HIPAA) with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates a need for further teaching?

"Information about a client can be disclosed to family members at any time."

A client who lost his belongings in a hurricane says, "Why should I start over? It will probably happen again anyway." Which of the following responses should the nurse make?

"It appears that you are feeling hopeless."

A nurse is talking with a client who is about to start using transcutaneous electrical nerve stimulation (TENS) to manage chronic pain. Which of the following statement should the nurse identify as an indication that the client needs further teaching?

"It's unfortunate that I have to be in the hospital for this treatment."

A nurse asks a client how he is feeling. The client states, "I'm feeling a bit nervous today." Which of the following responses should the nurse make?

"Please explain what you mean by the word 'nervous.'"

A nurse is orienting a newly licensed nurse about receiving telephone prescriptions. Which of the following statements by the newly licensed nurse should indicate a need for further teaching?

"Telephone prescriptions are transcribed into the nurse's notes."

A nurse is readmitting a client to the medical unit after a transfer to ICU following self-administration of an overdose of medication. The client looks down at the floor and mumbles, "Hello." Which of the following responses should the nurse make?

"Tell me a little more about what happen."

A nurse is having difficulty caring for a client due to variables affecting the communication process. Which of the following should the nurse identify as an interpersonal variable? (select all that apply.)

-Education -Gender -Perception

A nurse is performing care activities for a client in the zone of touch that requires consent. Which of the following activities should the nurse perform in this zone? (select all that apply.)

-Removing the client's dentures -Palpating for pedal edema -Counting a radial pulse

A nurse is receiving a provider's prescription for a client via telephone. Which of the following actions should the nurse take to ensure the accuracy of the telephone prescription? (Select all that apply)

-Repeat the order back to the provider -Question any part of the order that is unclear or inappropriate -Transcribe the order into the client's health record

A nurse is assessing a client who has narcolepsy. Which of the following findings should the nurse expect? (Select all that apply).

-Sudden attacks of sleep -Hallucinations at the onset of sleep

A nurse is caring for a client who is at risk for falls. Which of the following actions should the nurse take? (select all that apply.)

-Teach the client to use the call light -Keep the client's bed in the lowest position -Place a fall-risk identification band on the client's wrist

A nurse is caring for an older adult client who states, "I am afraid that I may fall while walking to the bathroom during the night." Which of the following actions should the nurse take?

Leave a nightlight on in the client's room

A nurse is assessing a client for pitting edema and notes an indentation of 6 mm (0.25 in) at the point of pressure. Which of the following notations should the nurse use to document the severity of the client's edema?

3+

A nurse should teach which of the following clients requiring crutches about how to use a three-point gait?

A client who has a right femur fracture with no weight bearing on the affected leg

A nurse is preparing a client for ambulation. Which of the following actions should the nurse take to determine the client's level of strength?

Ask the client to push her feet against the nurse's palms

A nurse is assessing a client's radial pulse and determines that the pulse is irregular. Which of the following actions should the nurse take?

Assess the apical pulse for a full minute

A client receives a wrong medication. The nurse who made the medication error should take which of the following actions first?

Assess the client

A nurse on a medical unit is caring for a client who suddenly becomes confused and drowsy. Additional data includes pulse 100/min, respiratory rate 24/min, BP 132/76 mm Hg, and temperature 36.8 degree C (98.2 degree F). Which of the following actions should the nurse perform?

Complete a neurological check

A nurse is admitting a client who has a partial hearing loss. Which of the following is the priority action by the nurse?

Determine if the client uses hearing aids

A nurse is caring for a client who requests prescription pain medication. Which of the following actions should the nurse perform first?

Determine the location of the pain

A nurse is preparing a client's evening dose of risperidone when the tablet falls on the countertop. Which of the following actions should the nurse take?

Discard the tablet and obtain another dose of medication

A nurse is caring for a client in the orientation phase of the nurse-client relationship. Which of the following communication techniques should the nurse use during this phase?

Elicit information from the client

A nurse is preparing an older adult client for a physical examination the provider is about to perform. Which of the following actions should the nurse take?

Explain to the client what is about to happen

A nurse is caring for a client who expresses anxiety about his impending surgery. Which of the following actions should the nurse take?

Explore the client's feelings

A nurse is caring for a client who has impaired mobility. Which of the following support devices should the nurse plan to use to prevent the client from developing plantar flexion contractures?

Footboard

A nurse is preparing to teach a client who has a low literacy level. Which of the following methods should the nurse plan to include?

Have short teaching sessions

A nurse is performing a cardiac assessment. Identify where the nurse should place the stethoscope to auscultate the client's apical pulse. (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.)

Lower left side of patient

A nurse is teaching a newly licensed nurse about transcribing prescriptions. Which of the following examples should the nurse include in the instructions?

Metformin 500mg, 1 tablet, PO, daily

A client smoking in his bathroom has dropped a cigarette butt into a wastepaper basket, which begins to smolder. Which of the following actions is the nurse's priority?

Move any clients in the immediate vicinity

A nurse is caring for an older adult client who was alert and oriented at admission, but now seems increasingly restless and intermittently confused. Which of the following actions should the nurse take to address the client's safety needs?

Move the client to a room closer to the nurse's station

A nurse asks a client to share personal stories. Which of the following types of intervention is the nurse using to promote the development of the nurse-client relationship?

Narrative interaction

A nurse is completing a client's history and physical examination. Which of the following information should the nurse consider subjective data?

Nausea

A nurse is caring for a client who states, "I have got to get out of this hospital! They have found my address and are coming for my family!" The nurse responds, "Don't worry, no one will harm your family." Which of the following types of communication breakdown does this response represent?

Offering false reassurance

A nurse is teaching a class on health promotion and illness prevention. The nurse should include that which of the following is an example of secondary prevention?

Performing monthly breast self-examinations Primary level of preventive care focuses on promoting a healthy life style and preventing the occurence of illness Secondary preventive care focuses on early detection, such as with monthly breast self-examinations Tertiary preventive care focuses on creating a better quality of life and decreasing physical deterioration

A nurse is caring for a client who is not cooperating with his care and demonstrates defiant behavior. The nurse chooses to confront this client. Which of the following approaches should the nurse use when using confrontation?

Point out inconsistencies in the client's behavior

A nurse is administering a cold therapy application to a client. Which of the following manifestations should the nurse identify as an indication for discontinuing the application due to a systemic response?

Shivering

A nurse is caring for a client who is at 36 weeks of gestation and is on the antepartum unit for continuous close observation. The client confides to the nurse that she doesn't think she will ever be a mother and begins to cry. Which of the following responses should the nurse make?

Sit quietly with the client and follow her cues

A nurse is caring for a client who is postoperative. The nurse should base her pain management interventions primarily on which of the following methods of determining the intensity of the client's pain?

The client's self-report of pain severity

A nurse is observing a client's nonverbal behavior. When evaluating this behavior, the nurse should factor in which of the following principles influencing nonverbal communication?

The client's sociocultural background influences nonverbal communication

A nurse is preparing to move a client who is only partially able to assist up in bed. Which of the following methods should the nurse plan to use?

Two nurses using a friction-reducing device

A nurse caring for a client is using active listening skills. Which of the following actions should the nurse take?

Use intermittent eye contact

A nurse is planning care for a client who is postoperative. Which of the following statements about pain management should the nurse consider when implementing client care? (select all that apply.)

Use of analgesics will eventually lead to addiction (DOUBLE CHECK)

A nurse is admitting a client from a long-term care facility. The nurse should use closed-ended questions when assessing which of the following factors?

When asking if the client took his medications this morning