Fundamentals Unit 3 Quiz

Which nursing interventions would the nurse implement to promote sleep for a client in a health care setting? Select all that apply. One, some, or all responses may be correct. 1. Restrict visitors. 2. Reduce lighting. 3. Provide activities during the day. 4. Decrease the sounds of the infusion alarms. 5. Increase the dosage of pain prescriptions at

2. Reduce lighting. 3. Provide activities during the day.

A client with hemiplegia becomes frustrated when performing skills. Which nursing intervention would motivate the client toward independence? 1. Establish long-range goals for the client. 2. Identify errors that the client can correct. 3. Reinforce success in tasks accomplished. 4. Demonstrate ways to promote self-reliance.

3. Reinforce success in tasks accomplished.

The nurse observes elevated superficial lesions filled with purulent fluid on a client's skin. Which type of lesion would the nurse document in the health record? 1. Wheal 2. Plaque 3. Pustule 4. Vesicle

3. Pustule

Which finding during a home health visit would prompt the nurse to provide a client with home safety instructions? Select all that apply. One, some, or all responses may be correct. 1. Area rugs on the floor 2. Clogged, dirty fireplace 3. Multiple electrical cords 4. Multiple prescribed medications 5. Wheeled walker with uneven legs

1, 2, 3, 4, 5

Which physiological changes of the musculoskeletal system would the nurse associate with aging? Select all that apply. One, some, or all responses may be correct. 1. Slowed movement 2. Cartilage degeneration 3. Increased bone density 4. Increased range of motion 5. Increased bone prominence

1, 2, 5

The nurse instructs a client about safety measures and precautions when taking care of a pressure ulcer. During a follow-up visit, the nurse finds increased tissue necrosis with damaged capillary beds. Which actions by the client would the nurse expect are the reason for the client's condition? Select all that apply. One, some, or all responses may be correct. 1. Massaging the reddened skin areas 2. Placing pillows between two bony surfaces 3. Using donut-shaped pillows for pressure relief 4. Keeping the head of the bed below 30 degrees 5. Using a bed pillow under the ankles to keep the heels off the bed surface

1, 3

The registered nurse is caring for a client with skin conditions. Which task could be delegated to a licensed practical nurse? 1. Applying dressings and administering oral medications 2. Teaching the client methods for decreasing sun exposure 3. Evaluating the treatment for effectiveness and adverse effects 4. Assessing the client's skin for acute and chronic problems

1. Applying dressings and administering oral medications

Applying a surgical mask in the correct order.

1. Find the top edge of the mask. 2.Hold the mask by its two strings or loops. 3.Secure the two top ties at the back of the head, with the ties above the ears. 4.Tie the two lower ties snugly around the neck with the mask well around the chin. 5.Gently pinch the upper metal band around the bridge of the nose.

Which skin color change would the nurse expect to see if a client with dark skin develops cyanosis? 1. Gray 2. Purple 3. Dark red 4. Purple-to-brownish

1. Gray

The nurse is teaching unlicensed assistant personnel about ways to prevent the spread of infection. The nurse decides to emphasize the need to break the cycle of infection. Which teaching would be priority? 1. Hand washing before and after providing client care 2. Cleaning all equipment with an approved disinfectant after use 3. Wearing personal protective equipment (PPE) when providing client care 4. Using medical and surgical aseptic techniques at all times

1. Hand washing before and after providing client care

During a routine clinic visit, an older adult complains about being unable to sleep well at night and then feeling sleepy throughout the next day. Which sleep promotion technique would the nurse advise? 1. Include age-appropriate exercise daily 2. Include age-appropriate exercise daily 3. Avoid naps during the daytime 4. Have a hot cup of tea at bedtime

1. Include age-appropriate exercise daily

Which infection requires airborne precautions? Select all that apply. One, some, or all responses may be correct. 1. Measles 2. Influenza 3. Clostridium difficile 4. Bacterial meningitis 5. MRSA

1. Measles

Which concern will the nurse keep in mind when a client has been taking a benzodiazepine? 1. Rebound insomnia may occur if the medication is discontinued abruptly. 2. Lifelong treatment is often required 3. Higher doses are needed to accommodate physiological changes during pregnancy 4. These medications have both analgesic and antidepressant properties.

1. Rebound insomnia may occur if the medication is discontinued abruptly.

The community nurse is assessing an older adult client who lives alone at home. The nurse finds that the client refrains from physical activity for fear of falling when walking. Which intervention(s) by the nurse are beneficial to promote a healthy lifestyle? Select all that apply. One, some, or all responses may be correct. 1. Instruct the client to apply bedside rails. 2. Encourage the client to wear nonskid shoes. 3. Suggest that the client use an assistive device. 4. Ask the client to install handrails in the bathroom. 5. Help the client rearrange furniture in the house.

2, 3, 5

A client with left-sided weakness is learning how to use a cane. The nurse would demonstrate proper use of the cane by holding it where? 1. On alternating sides 2. On the right side 3. On the side of the weakness 4. On the side of the client's choice

2. On the right side

A client reports to the nurse sleeping until noon every day and taking frequent naps during the rest of the day. Which would the nurse do initially? 1. Encourage the client to exercise during the day. 2. Arrange a referral for a thorough medical evaluation. 3. Explain that this behavior is an attempt to avoid facing daily responsibilities. 4. Identify that the client is describing clinical findings associated with narcolepsy.

2. Arrange a referral for a thorough medical evaluation.

The nurse is changing the soiled bed linens of a client with a wound that is draining seropurulent exudate. Which personal protective equipment (PPE) would the nurse wear? 1. Mask 2. Clean gloves 3, Sterile gloves 4. Show covers

2. Clean gloves

Which age-related skin change occurs in older adult clients and increases their potential for developing pressure ulcers? 1. Atrophy of the sweat glands 2. Decreased subcutaneous fat 3. Stiffening of the collagen fibers 4. Degeneration of the elastic fibers

2. Decreased subcutaneous fat

When providing care for a client with quadriplegia, which nursing intervention assists in decreasing the potential occurrence of pressure ulcers? 1. Avoid massaging the client's legs. 2. Frequently reposition the client on a scheduled basis. 3. Increase the fiber content in the client's food. 4. Encourage the client to participate in weight-bearing exercises.

2. Frequently reposition the client on a scheduled basis.

Which priority teaching intervention would the nurse include in the care plan for a client who has insomnia? 1. Medication administration procedures 2. Sleep and cognitive changes 3. Dietary measures to be followed at night 4, Nonpharmacological measures, including sleep techniques

2. Sleep and cognitive changes The nurse would first teach about sleep and cognitive changes to the client with insomnia. The nurse can teach about medication administration procedures, but this is not the priority. The nurse can teach dietary measures to be followed at night after teaching about sleep and behavioral changes. Teaching about nonpharmacological procedures is also not the priority nursing intervention.

Which nursing action is most appropriate to help reduce the likelihood of an older adult client falling during the night? 1. Moving the client's bedside table closer to the bed 2. Encouraging the client to take an available sedative 3. Instructing the client to call the nurse before going to the bathroom 4. Assisting the client to telephone home to say goodnight to the spouse

3. Instructing the client to call the nurse before going to the bathroom

Which condition would the nurse suspect if a client's laboratory reports show white blood cells (WBCs) in the urine? 1. Pyelonephritis 2. Kidney trauma 3. Kidney infection 4. Acute tubular necrosis

3. Kidney infection

While assessing the client for a pressure injury, the nurse identifies exposed bone and tendons. Which stage would the nurse document for this pressure injury? 1. Stage 1 2. Stage 2 3. Stage 3 4. Stage 4

4.

A registered nurse is teaching a student nurse about factors that influence sleep. Which scenario explained by the registered nurse is an example of a lifestyle factor? 1. "A client reports trouble falling asleep because of thinking about stress at work." 2. "A client in the intensive care unit has not slept properly because of noises and disturbances." 3. "A client who has been taking antidepressants reports drowsiness and lack of sleep." 4. "A client who works rotating overnight shifts reports fatigue and difficulty sleeping through the night."

4. "A client who works rotating overnight shifts reports fatigue and difficulty sleeping through the night."

When teaching an older adult client about skincare to prevent pressure ulcers, which client statement indicates a misunderstanding? 1. "I should gently pat my skin." 2. "I should use mild, heavily fatted soap." 3. "I should wash my skin with tepid, rather than hot water." 4. "I should apply powders or talc on a perineum wound."

4. "I should apply powders or talc on a perineum wound."

The registered nurse (RN) is caring for a client who is on isolation precautions. Which tasks can be safely assigned to the nursing assistive personnel? Select all that apply. One, some, or all responses may be correct. 1. Assessing vital signs 2. Administering injections 3. Assessing wound drainage 4. Bringing equipment to the client's room 5. Transporting the client to a diagnostic tes

4. Bringing equipment to the client's room 5. Transporting the client to a diagnostic tes

Which action would the nurse take to prevent venous thrombus formation after abdominal surgery? 1. Keep the client in a gatch bed to elevate the knees. 2. Have the client dangle the legs off the side of the bed. 3. Help the client use an incentive spirometer every hour. 4. Encourage the client to ambulate multiple times daily.

4. Encourage the client to ambulate multiple times daily.

Which action will the nurse take to prevent skin breakdown for a client who is on bed rest? 1. Massage the bony prominences. 2. Promote range-of-motion activities. 3. Maintain a sheepskin pad under the client. 4. Encourage the client to move in the bed as much as possible.

4. Encourage the client to move in the bed as much as possible.

A client has a pressure ulcer that is full thickness with necrosis into the subcutaneous tissue down to the underlying fascia. The nurse would document the assessment finding as which stage of pressure ulcer? 1. Stage I 2. Stage 2 3. Stage 3 4. Unstageable

4. Unstageable

Arrange the order of pathophysiology involved with the development of pressure ulcers on the sacrum, hips, and ankles of a client with quadriplegia.

Quadriplegic clients are immobile or wheelchair bound and incapable of changing position without assistance; therefore they have more chances of developing pressure ulcers. Tissue compression from pressure restricts blood flow to the skin, resulting in reduced tissue perfusion and oxygenation and, eventually, leading to cell death and the development of pressure ulcers. 1. Development of pressure ulcers Incorrect2.Local tissue compression Incorrect3.Restriction of blood flow Correct4.Local cell death Incorrect5.Reduced tissue perfusion