Fundamentals Quiz 2

A nurse is planning to administer pain medication to a client who has pain following abdominal surgery. Which of the following actions should the nurse take first? a. Use the pain scale to determine the client's pain level b. Discuss the adverse effects of pain medication with the client c. Obtain the client's vital signs d. Check the client's allergies

. Use the pain scale to determine the client's pain level

A nurse is caring for a client who postoperative and who has an indwelling urinary catheter to gravity drainage. The nurse notes no urine output in the past 2 hrs. Which of the following actions should the nurse take first? A. Check to determine if the catheter tubing is kinked b. Palpate the bladder c. Obtain a prescription to irrigation the catheter with 0.9% sodium chloride. d. Encourage the client to drink more fluids.

A. Check to determine if the catheter tubing is kinked

A nurse is planning care for a client who has a prescription for collection of a sputum specimen for cultural and sensitivity. Which of the following actions should the nurse take when obtaining the specimen? A. Collect the specimen upon arising in the morning. B. Force fluids during the day and collect the specimen in the evening C. Collect the specimen after antibiotics have been started D. Collect 2 ml of sputum before sending it to laboratory

A. Collect the specimen upon arising in the morning

A nurse is planning care for an adult client who has fluid volume excess. Which of the following interventions should the nurse plan to include to monitor the client's weight? a. Calibrate the scales weekly B. Use a different scale each time C. Weigh the client on arising D. Weigh the client without clothing

C. Weigh the client on arising

A nurse is preparing to assist with ambulation of an older adult client who was on bed rest for 3 days. Which of the following actions should the. nurse take to decrease the risk of a fall? a. Use a gait belt during ambulation b. Ensure the client is earring socks before ambulating c. Instruct the client to sit on the edge of the bed for 15 encodes before ambulating. d. walk 2 feet behind the clients doing adulation

a. Use a gait belt during ambulation It will decrease the risk of falls

A nurse is administering a cleansing enema to a client who is scheduled for a diagnostic procedure. which of the following actions should the nurse take? a. Lubricate up to 3.2 cm (1.25 in) of the tip of the rectal tube b. Position the client on his right side c. Insert the tip of the tubing 8 cm (3.1 in) D. Hold the enema container 61 cm (24 in) above the rectum

c. Insert the tip of the tubing 8 cm (3.1 in) Should be a. 5-8 cm b. left side in sims position d.max of 45 cm

A nurse is caring for a toddler at a well-child visit when the mother calls to the nurse, "Help! My baby is choking on his food." Which of the following findings indicates the toddler has an airway obstruction? A flushing of the skin. B. Inability of the toddler to cry or speak C. Presence of Nausea and mild emesis D. Capillary refill time 1.5 sec

B. Inability of the toddler to cry or speak

A nurse is preparing to anchor with tape the catheter tube for a male client who has a newly inserted indwelling urinary catheter. At which of the following locations should the nurse tape the catheter? A. Lateral thigh B. Lower abdomen C. Mid-abdominal region D. Medial thigh

B. Lower abdomen

A nurse is preparing to insert an NG tube for a client who has a bowel obstruction. Which of the following actions should the nurse take first. A. Provide the client with a glass of water B. Assist the client to a sitting position. C. Explain the procedure to the client D. Measure the length o tubing to be inserted.

C. Explain the procedure to the client

A nurse is chasing the dressings for a client who is 3 days postoperative following a cholecystectomy. The nurse observes yellow, thick drainage on the dressing. The nurse should document this finding as which of the following types of drainage? a. Sanguineous exudate b. Serous exudate c. Serosanguineous exudate. D. Purulent exudate

D. Purulent exudate

A nurse is planning care for a group of clients who are receiving oxygen therapy. Which of the following clients should the nurse plan to see first? a. A client who has heart failure and is receiving 100% oxygen via a partial rebreather mask b. A client who has emphysema and is receiving oxygen at 3L/min via a transtracheal oxygen cannula c. a client who has an old tracheostomy and is reciting 40% humidified oxygen via tracheostomy collar d. a client who has COPD and is receiving oxygen at 2 L/ min via nasal cannula

a. A client who has heart failure and is receiving 100% oxygen via a partial rebreather mask

A nurse is replacing the surgical dressings on a client who had abdominal surgery. Which of the following actions should the nurse take? a. Don clean gloves to remove the old dressing b. Loosen the dressing by pulling the tape away from the wound c. Remove the entire old dressing at once d. Open sterile applies after applying sterile gloves

a. Don clean gloves to remove the old dressing First you have to remove the dressing before you apply sterile technique...

A nurse is preparing to administer eye drops to a client following surgery. Which of the following actions should the nurse take when installing the eye drops? a. Drop the eye medication in the outer third of the lower conjunctival sac b. Apply gentle pressure in the outer opening of the eye for 2 min c. Hold the eye dropper 0.5 cm (0.2 in) from the cornea d. Instruct the client to close eyes tightly after administration.

a. Drop the eye medication in the outer third of the lower conjunctival sac

A nurse is caring for a client who is postoperative following a vaginal hysterectomy and asks for a drink. Her postoperative diet prescription reads: clear liquids; advance diet as tolerated. Which of the following responses should the nurse make? a. "Lunch trays should be here within the hour" b. "I am going to listen to your abdomen" c. "I'll get you some water to drink" d. "I would wait a bit, or you could feel sick."

b. "I am going to listen to your abdomen" A common reason clients experience nausea and vomiting after surgery is delayed gastric emptying time or decreased peristalsis. The nurse should osculate the client's abdomen to determine the presence of bowel sounds before clear liquids can be administered.

A nurse is teaching a client who is recovering from gallbladder surgery how to use an incentive spirometer. Which of the following information should the nurse include in the teaching? a. Exhale slowly to reach goal volume b. Hold breath for 5 seconds after goal volume is reached c. Continue to deep breathe between each cycle. d. Limit repeat pattern ob breathing to 5 breaths

b. Hold breath for 5 seconds after goal volume is reached The nurse should instruct the client to hold her breath for 3-5 seconds after reaching maximal inspiratory volume. This decreases the collapse of alveoli, which helps to prevent the risk of atelectasis and pneumonia

A nurse is assessing a client who has an onset of sever back pain of unknown origin. Which of the following questions should the nurse ask to encourage discussion with the client? a. "Does the medication you're taking relieve the pain?" b. "Can you point to where the pain is the worst?" c. "What do you think caused the onset of your pain?" d. "Changing positions makes your pain worse, right?"

c. "What do you think caused the onset of your pain?" It is an open ended question

A nurse is assisting a client who is eating at mealtime. The client grabs her neck with both hands and appears frightened. Which of the following actions should the nurse take first? a . Place an oxygen mask on the client b. check the client's pulse c. Determine whether the client is able to breather. d. Wrap arms around the client from behind

c. Determine whether the client is able to breather.

A nurse is caring for a client who has an NG tube for intermittent enteral feedings. Which of the following actions should the nurse take? a. Auscultate for bowel sounds after each feeding. b. Ensure the formula is cold before administering. c. Elevate the client's head of bed 45 degrees before the feeding d. Flush the tubing with 15 mL of water after the enteral feeding.

c. Elevate the client's head of bed 45 degrees before the feeding To prevent aspiration

A nurse is preparing to remove an NG tube for a client who had a partial colectomy. Which of the following actions should the nurse take? a. Maintain suction while removing the NG tube b. Install 100 mL of air into the NG tube before removal c. Pinch the NG tube while removing the tube d. Instruct the client to breathe in and out during the removal of the NG tube

c. Pinch the NG tube while removing the tube The nurse should pinch the NG tube while removing the tube to decrease the risk of aspiration of any gastric contents Should be.. Suction turned off 50 ml of air Deep breath and hold during removal

A nurse is caring for a client who is receiving an IV fluid replacement. Which of the following findings should the nurse identify as infiltration of the IV infusion site? a. Redness at the IV catheter entry site b. A palpable cord is felt along the vein used for the infusion c. Taut skin around the IV catheter site that is cool to the touch d. Bleeding at the IV insertion site

c. Taut skin around the IV catheter site that is cool to the touch should be ... a. might be infection b.might be phlebitis d. IV system is not intact

A nurse is caring for a client who has major fecal incontinece and reports irritation in the perianal area. Which of the following actions should the nurse take first? a. Apply a fecal collection system b. Apply a barrier cream c. Cleanse and dry the area d. Check the client's perineum

d. Check the client's perineum It is the first thing that should be done

A nurse is collecting a urine specimen for culture and sensitivity for a client who has a urinary tract infection. The client has an indwelling urinary catheter in place. Which of the following actions should the nurse take? a. Withdraw the specimen from the drainage bag. b. Cleanse the collection port with soap and water c. Place the specimen in a clean specimen cup d. Clamp the tubing below the collection port

d. Clamp the tubing below the collection port Should do this so fresh uncontaminated urine to collect before withdrawing the specimen through the port and placing it in a sterile specimen cup

A nurse is caring for a client who had a mastectomy and has self-suction drainage evacuator in place. Which of the following actions should the nurse take to ensure proper operation of the device? a. Irrigate the tubing with sterile normal water once each shift b. Cleanse the opening with soap and water after emptying c. Maintain the tubing above the level of the surgical incision d. Collapse the device of air after emptying

d. Collapse the device of air after emptying The nurse should collapse the device of air after emptying the contents periodically to create enough suction to pull fluid exudate into the collection area of the device

A nurse is planning to collet a stool specimens for ova and parasites from a client who has diarrhea. Which of the following actions should the nurse take when collecting the specimen? a. Instruct the client to defecate into the toilet bowl. b. transfer the specimen to a sterile container. c. Refrigerate the collected specimen d. Place the stool specimen collection container in a biohazard bag

d. Place the stool specimen collection container in a biohazard bag

A nurse is performing a straight urinary catheterization for a female client who has urinary retention. Which of the following actions indicates the nurse is maintaining sterile technique? A. Applies sterile gloves to open catheter package b. Wipes the labia minor in an anteroposterior direction. c. Spreads the labia with the dominant hand. D. Uses one cotton ball to wipe the right and left major.

b. Wipes the labia minor in an anteroposterior direction. should be... a. sterile gloves after opening package c.non dominant hand d.Use a separate cotton ball

A nurse is providing teaching to a client who has a new colostomy about proper care. Which of the following information should the nurse include in the teaching? a. change the colostomy before breakfast b. cleanse the skin around the stoma with warm water c. Change the pouch everyday d. place an aspirin in the ostomy pouch to decrease the odor

b. cleanse the skin around the stoma with warm water Using soap can leave a residue on the skin and cause poor adherence of the pouch adhesive

A nurse is performing eye irrigation for a client who was exposed to smoke and ash. Which of the following actions should the nurse take? a. Hold the irrigator 1.25 cm (0.5 in) above the eye b. Direct the irrigation solution upward toward the upper eyelid. c. exert pressure on the bony prominences when holding the eyelids open d. direct the irrigation from the outer cants to the inner cants of the eye

c. exert pressure on the bony prominences when holding the eyelids open

A nurse is helping a client change his hospital gown. The client has an IV infusion on an infusion pump. Which of the following actions should the nurse take first? a. Remove the sleeve of the gown from the arm without the IV line b. Slow the infusion using the roller clamp c. Disconnect the IV line from the pump d. Bring the IV-solution and tubing from the outside to the end side of the sleeve of the gown

a. Remove the sleeve of the gown from the arm without the IV line

A nurse is planning care for a client who is confused and requires a prescription for wrist restraints. Which of the following interventions should the nurse include in the plan of care? a. Renew the prescription for the use of restraints within 24 hours b. Secure the restraints with the buckle side next the client's skin c. Ensure 4 fingers can be inserted under the secured restraint d. Remove the restraint every 3 hr.

a. Renew the prescription for the use of restraints within 24 hours Remove at least every 2 hrs Buckle to the outside 2 fingers

A nurse is planning care for a client who has a wound infection following abdominal surgery. To promote healing and fight infection, which of the vitamins and minerals should the nurse plan to increase in the client's diet? a. Vitamin C and zinc b. Vitamin D c. Vitamin K and Iron d. Calcium

a. Vitamin C and zinc The client's body needs both vitamin C and zinc to help fight a wound infection. The clients should receive a multivitamin, and a mineral supplement of both. In addition, vitamin E supplements also are needed to aid in skin and wound healing Vitamin D is for calcium Calcium for ostoperosis Vitamin k and iron is for normal clotting of blood

A nurse is performing suctioning for a client who has a tracheostomy. Which of the following actions should the nurse take? a. pull suction catheter back 1 cm (0.5 in) if the client starts coughing. b. Allow 30 seconds between suctioning passes c. Hyperventilate the client with 50% oxygen for 30 seconds d. Perform a maximum of 4 passes with the suction catheter

a. pull suction catheter back 1 cm (0.5 in) if the client starts coughing. Should be..... b. allow one minute c. 10%, 2 minutes d. 3 passes

A nurse is caring for a client who has a history of dysrhythmias. Upon entering the room, the nurse discovers the client is unresponsive to verbal or painful stimuli, has no respirations, and is pulseless. which of the following actions should the nurse take first? a. start chest compressions b. Provide breaths with a manual resuscitation bag. c. Administer oxygen d. establish an airway

a. start chest compressions Start CPR

A nurse is chasing the bed linens for a client who is on bed rest. Which of the following actions should the nurse plan to take? a. Place the soiled lines on the chair while making the bed. b. Hold the linens away from the body and clothing c. Place the lines on the floor until able to place it in a linen bag. d. Shake the clean linens to unfold

b. Hold the linens away from the body and clothing Place in linnen bag immediately

A nurse is chasing the dressings for a client who has two Penrose drains near an abdominal incision. Which of the following adhering device is the best choice for the nurse to use to decrease skin irritation? a. abdominal binder b. Montgomery straps c. Hypoallergenic tape d. Plastic tape

b. Montgomery straps They are adhesive strips, they have holes for using gauze to tie the dressing securely. When you need to change just untie the straps

A nurse is caring for an older adult client who has dysphagia following a cerebrovascular acciedent Which of the following actions should the nurse take when assisting the client at mealtime? a. Encourage the client to drink fluid before swallowing food. b. Offer the client tart or sour foods first c. Tilt the client's head backward when swallowing d. Turn on the television

b. Offer the client tart or sour foods first To encourage saliva production The head should always be tilted forward to swallow Drinking liquids will put him at risk of choking Television??? NO

A nurse is preparing to administer an intramuscular injection to a client who is overweight. Which of the following sites should the nurse select for the injection? a. The lower, medial quadrant of the buttock near the coccyx. b. The side hip between the iliac crest and anterior iliac spine. c. The tissue of the posterior upper arm d. The lower, inner thigh 4 finger widths above the patella

b. The side hip between the iliac crest and anterior iliac spine. This is the ventrogluteal site

A nurse is applying antiembolitit stockings for a client who has a history of deep vein thrombosis. Which of the following actions should the nurse take when applying the stockings? a. Roll the stockings partially down if too long. b. Remove the stockings once per day c. Bunch and pull the stockings half way up the calf. d. Turn the stocking inside out up to the heel before applying

d. Turn the stocking inside out up to the heel before applying

A nurse is changing the dressings for a client recovering from an appendectomy following a ruptured appendix. The client's surgical wound is healing by secondary intention. Which of the following observations should the nurse report to the provider? a. tenderness when touched b. Pink, shiny tissue with a granular appearance c. Serosanguineous drainage d. a halo of erythema on the surrounding skin

d. a halo of erythema on the surrounding skin It might indicate underlying infection

A nurse is caring for a client who has a hearing impairment. Which of the following interventions should the nurse use when speaking with the client? a. Speak directly into the client's impaired ear. b. Exaggerate lip movements c. speak loudly d. face the client while speaking

d. face the client while speaking

A nurse is providing teaching to a group of unit nurses about wound healing by secondary intention. Which of the following information should the nurse include in the teaching? a. The wound edges are well-approximated b. The wound is closes at a later date c. a skin graft is placed over the wound bed d. granulation tissue fills the wound during healing

d. granulation tissue fills the wound during healing The wound is left open and heals by secondary intention, it occurs 5-21 days. Open wounds place the client at risk of wound infection