Fundies 2019 A

Nurse is planning care for a client who had a stroke. What should be assigned to the assistive personal? (SATA)

-Assist the client with a partial bed bath. -Measure the client's BP after the nurse administers antihypertensive meds. -Use a communication board to ask what the client wants for lunch.

A nurse in a long-term care facility is caring for a client who dies during the nurse's shift. Identify the sequence in which the nurse should perform the following steps.

-Place a name tag on the body -Obtain the pronouncement of death from the provider -Remove tubes and indwelling lines -Wash the client's body -Ask the client's family members if they would like to view the body

Caring for a client who died. Which order do you do the steps?

1. Obtain order 2. Remove tubes 3. Wash client 4. Ask family 5. Place the tags

Nurse performing a skin assessment for a client who expresses concern about skin cancer. What findings should the nurse identify as a potential indication of a skin malignancy?

A mole with an asymmetrical appearance

Nurse caring for a client who has a sodium level of 125. What findings should the nurse expect?

Abdominal Cramping

Nurse caring for client who has herpes zoster. Client asks about complementary and alternative therapies for pain control. Nurse should inform client that this condition is a contraindication for which of the following therapies?

Acupuncture

A nurse is providing discharge teaching to a client about self-administering heparin.

Administer medication in abdomen

Nurse is preparing an education program for staff about advocacy. What information should the nurse include?

Advocacy ensures clients' safety, health, and rights.

nurse is preparing an injection for opioid medication. Draws 1 mL from 2mL vial, what should the nurse do?

Ask another nurse to observe medication waste?

A nurse assessing a client who has required bed rest for past month. Indication of thrombophlebitis?

Calf Swelling

Nurse receives report about a client getting IV fluids infusing 125ml/hr but notes he has only gotten 80 mL over the last 2 hours. What should nurse do first?

Check IV tubing for obstruction

Nurse is evaluating a client's use of cane. What is the correct use?

Client holds the cane on the stronger side of the body.

Postop client with fluid volume deficit. Changes indicate successful treatment

Decrease in heart rate

A nurse is caring for a child who has a prescription for a blood transfusion. The parents have refused the treatment due to religious beliefs. Which of the following actions should the nurse take?

Examine personal values about the issue.

A nurse is caring for a client who requires an NG tube for stomach decompression. Which of the following actions should the nurse take when inserting the NG tube?

Help the client take sips of water to promote insertion of the NG tube

Preparing to apply dressing to stage 2 pressure injury. Which type of dressing should the nurse use?

Hydrocolloid

Deep tendon reflex -- patellar reflex

Knee picture

A nurse is caring for a client who is postoperative and has signs of hemorrhagic shock. When the nurse notifies the surgeon, he directs her to continue to measure the client's vital signs every 15 min and call him back in 1 hr. From a legal perspective, which of the following actions should the nurse take next?

Notify the nursing manager.

nurse on a medical-surgical unit is caring for a client who has a new prescription for wrist restraints. Which of the following actions should the nurse take?

Pad the client's wrist before applying the restraints

Reviewing client's fluid and electrolytes status. What should nurse report to provider?

Potassium 5.4

nurse is caring for a client who is expressing anger about his diagnosis of colorectal cancer. Which of the following actions should the nurse take?

Reassure the client that this is an expected response to grief.

Nurse is reviewing EBP about administration of O2 therapy

Regulate O2 via nasal canula no more than 6L

Nurse is preparing for change of shift. Which document or tools should the nurse use to communicate?

SBAR

Nurse lifting bedside cabinet. Prevent self-injury by?

Standing close to cabinet when lifting

Nurse using an open irrigation technique for client's catheter. What action should nurse take?

Subtract amount of irritant used from client's urine output.

A nurse is performing a home safety assessment for a client who is receiving supplemental oxygen. Which of the following observations should the nurse identify as proper safety protocol?

The client uses no acetone nail polish remover.

nurse is performing a follow-up visit for a client who has a G-tube through which they receive intermittent feedings and medications. The client has recently developed diarrhea. Which of the following findings should the nurse identify as a cause of the diarrhea?

The client's care giver washed out the feeding bag once every 24 hours with warm water

Nurse caring for a client who has dementia. What interventions should be taken to minimize risk for injury?

Use bed exit alarm system

Nurse is planning strategies to manage time effectively for client care. What should the nurse implement?

Use the planning step of the nursing process to prioritize client care delivery.

Nurse is teaching a client and his family how to care for the client's tracheostomy at home. Which of the following should the nurse include in the teaching?

Use tracheostomy covers when outdoors

Nurse caring for a client who has diarrhea due to shigella. Precautions to implement?

Wear a gown when caring for the client

A nurse is caring for a client who has a terminal illness and is approaching death. The client's respirations are noisy from secretions in her airway and she is short of breath. Which of the following actions should the nurse take?

turn the client every 2 hours

A nurse is assessing an older adult client's risk for falls. Which of the following assessments should the nurse use to identify the client's safety needs?

-Pupil clarity -visual fields -visual acuity

Math Question 7 hours

107 mL/hr

nurse is preparing to administer 750 mL of 0.9% sodium chloride IV to infuse over 7 hr. The nurse should set the infusion pump to deliver how many mL/hr?

107 mL/hr

Nurse caring for client postop. When nurse prepares to change dressing, client says it hurts. Which intervention is the nurse's priority action?

Administer pain meds 45 minutes prior to dressing change.

Nurse responding to call light and finds client on bathroom floor. Which of the following actions should the nurse take FIRST?

Check client for injuries

A nurse is assessing 4 adult clients. Which of the following physical assessment techniques should the nurse use?

Ensure the bladder of the BP cuff surrounds 80% of their arm.

Nurse caring for client who has prostate cancer. Provider discusses treatment options and leaves room. Client declines to talk about concerns. Which of the following statements should the nurse make?

I am available to talk if you should change your mind.

Nurse caring for client at end of life. Which statement by client's partner is effective coping?

I am relying on support from out family during this time

Nurse caring for postop client following knee arthroplasty and requires thigh high compression sleeves. What should the nurse do?

Make sure two fingers can fit under the sleeve.

Nurse auscultating anterior chest who is newly admitted. Listen---

Normal breathing sounds

A nurse is caring for a group of clients. Which of the following actions should the nurse take to prevent spread of infection?

Place a client who has TB in a room with negative-pressure airflow

Nurse planning to insert IV for an older adult client. What actions should the nurse plan to take?

Place the client's arm in a dependent position.

nurse is assessing a client who reports increased pain following pt. Which of the following questions should the nurse ask hen assessing the quality of the client's pain?

Sharp & Dull

A nurse is using an open irrigation technique to irrigate a client's indwelling urinary catheter. Which of the following actions should the nurse take?

Subtract the amount of irrigant used from the client's urine output.

Nurse caring for client approaching death. SOB, noisy respirations. What should they do?

Turn client 2 hours

Nurse manager is reviewing medication documentation. Which of the following statements should the nurse plan to include in teaching?

Use the complete name of the medication magnesium sulfate.

nurse receives report about a client who has 0.9% sodium chloride infusing IV at 125 mL/hr. When the nurse performs the initial assessment, he notes that the client has received only 80 mL over the last 2 hr. Which of the following actions should the nurse take first?

check IV tubing

A nurse is administering 1 L of 0.9% sodium chloride to a client who is postoperative and has fluid-volume deficit. Which of the following changes should the nurse identify as an indication that the treatment was successful?

decrease HR

A nurse is reviewing evidence-based practice principles about administration of oxygen therapy with a newly licensed nurse. Which of the following actions should the nurse include?

regulate oxygen via nasal cannula at a flow rate of no more than 6 L/min

Nurse is preparing to administer enoxaparin subcutaneously. Which of the following actions should the nurse take?

Administer the medication with the needle at a 45-degree angle.

Nurse caring for a client who has a respiratory infection. What technique should she use when preforming nasotracheal suctioning?

Apply intermittent suction when withdrawing he catheter.

Nurse admitting new client. Which of he following actions should the nurse take while performing medication reconciliation?

Compare the client's home medications to the providers prescriptions

A nurse is admitting a client who has an abdominal wound with a large amount of purulent drainage. Which of the following types of transmission precautions should the nurse initiate?

Contact precautions

Nurse caring for client postop refuses to use incentive spirometer following major abdominal surgery. Nurse's priority?

Determine the reason why the client is refusing to use the IS

Nurse is caring for a client who has pharyngeal diphtheria. Transmission precautions?

Droplet

A nurse is admitting a client who is having an exacerbation of heart failure. In planning this client's care, when should the nurse initiate discharge planning?

During the admission process

Nurse is assessing readiness to learn about insulin self-administration. What indicates the client is ready to learn?

I can concentrate best in morning.

Nurse providing discharge instructions for client who will be using a walker. Which statement indicates an understanding of the teaching?

I will hire someone to trim the tree that hands low over the stairs of my front porch.

A nurse caring for a client who asks about the purpose of advance directives. Which of the following statements should the nurse make?

Indicate form of treatment a client is willing to accept in the event of a serious illness

Client postop is verbalizing pain at a 2 on a scale from 0-10. Indication that client understands pain management?

It might help me to listen to music while lying in bed.

nurse is talking with an older adult client who is contemplating retirement. The client states, "I keep thinking about how much I enjoy my job. I'm not sure I want to retire." Which of the following responses should the nurse make?

Let's talk about how the change in your hob status will affect you.

Postop, signs of hemorrhagic shack. Nurse notifies surgeon and he said to continue to monitor vitals every 15 minutes and report in one hour. What should the nurse do next?

Notify nurse manager

Nurse is administering optic ear medication on an adult client. Which action should be done to ensure the medication reached the inner ear?

Press gently on the tragus of the client's ear.

A nurse is talking with the partner of an older adult male client who has dementia. The client's partner expresses frustration about finding time to manage household responsibilities while caring for his partner. The nurse should identify that he is going through which of the following types of role-performance stress?

Role overload

Nurse talking with a client's partner. She is having frustrations about managing responsibilities and care. What type of role performance stress is this?

Role overload

A nurse is evaluating a client's use of a cane. Which of the following actions should the nurse identify as an indication of correct use?

The client holds the cane on the stronger side of her body.

A nurse is educating a client who has a terminal illness about declining resuscitation in a living will. The client asks, "What would happen if I arrived at the ED and I had a difficulty breathing?" Which of the following responses should the nurse make?

We would give you oxygen through a tube in your nose.

A nurse is initiating a protective environment for a client who has had an allogenic stem cell transplant. Which precaution should the nurse plan for this client?

a. Make sure the client wears a mask when outside her room if there is construction in the area.