Nursing I: Fundamentals 2 Practice Test

A nurse is checking the IV insertion site for infiltration for a client who is receiving fluids replacement. Which of the following would the SN identify as infiltration of the IV infusion site?

*Taut Skin around the IV cath site that is cool to the touch.

When ambulating a frail, older adult client, the nurse should

*Use the transfer belt if the client is unsteady

A client is hospitalized for an infection of a surgical wound following abd surgery. To promote healing and fight wound infection the nurse plans to arrange to increase the client's intake of:

*Vitamin C and Zinc

A nurse is in a public building when someone cries out "Help! I think he is having a heart attack!" The nurse responds to the scene and finds the unconcious adult lying on the floor. Another bystander has obtained an AED. The nurse's first action, after making certain someone has called for EMS, should be to

Administer cardiac compressions.

In planning care for a client with surgical wound helating by secondary intention, the nurse can anticipate that the client will

Be at an increased susceptibility for infection.

A post-op nurse has an indwelling catheter in place to gravity drainage. The nurse notes that the client's urine bag has been empty for 2 hours. The first action the nurse shoudl take is to:

Check to see if the tubing was kinked.

A nurse is assisting a client who is eating at mealtime. The client grabs her neck with both hands and appears frightened. WOTFA should the nurse take first?

Determine whether the client is able to breathe.

A client is recovering from an appendectomy for a ruptured appendix has a surgical wound healing by secondary intention. When changing the client's dressing, which observation should the nurse report to the client's surgeon?

*A halo of erythemia on the surrounding skin

A nurse is caring for a client who is incontinent of loose stool and is reporting a painful perineum. Which of the following is the priority nursing action?

*Check the client's perineum

When obtaining a urine specimen for a culture and sensitivity from an indwelling catheter, the nurse should:

*Clamp tubing below the collection port

While changing the linen on the client's bed, the nurse should

*Hold the linen away from his body and clothing.

Which nursing action prevents injury to a client's eye during the administration of eye drops

*Holding the tip of the container above the conjunctival sac

A client returning from the surgical suite following a vaginal hysterectomy is awake and asking for something to drink. Her post-op diet prescription reads: " clear liquids, advance diet as tolerated." Which of the following is appropriate for the nurse to tell the patient?

*I am going to listen to your abdomen

A nurse takes an older adult lient who has dysphagia following a CVA to the dining room for dinner. When assisting the client at mealtime, the nurse should:

*Offer the client tart or sour foods. (This makes it easier for them to swallow)

A nurse is planning to collect a liquid stool specimen from a client for ova and parasites. WOTFA should the SN take?

*Place the stool in a biohazard bag.

The nurse is caring for an adult who has fluid volume excess. When weighing the client, the nurse should

*Weight the client upon rising.

A nurse is assessing a client admitted with sudden onset of severe back pain of unknow origin. Which question would be most effective for the nurse to use to elicit further information from this client about his pain?

*What do you think caused the onset of your pain?

A nurse is caring for several clients who are receiving O2 therapy. Which client should the nurse assess most frequently for manifestations of oxygen toxicity?

100% oxygen via partial rebreathing mask

A client is recovering fromg allbladder surgery performed under general anesthesia. The nurse should encourage the client to use the incentive spirometer how many times per hour?

4-5 times per hour

When replacing a client's surgical dressing, the nurse should:

*Don clean gloves to remove the old dressing

A nurse is preparing to instert a NG tube for a client admitted with bowel obstruction. Which of the following should the nurse do first?

*Explain the procedure to the client.

A client develops a fecal impaction. Before digital removal of the mass, which type of enema should the nurse give to loosen the feces?

Oil Retention

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?

Pinch the tube while removing.

A nurse is teaching a lient with a new colostomy about how to irrigate the ostomy. The nurse realizes that the client needs further teaching when the client

Positions the irrigating solution bag 30 inchees above the stoma

CPR has been initiated for the client in the ER. The nurse understands that a critical concept related to effective cardiac chest compressions is the need to:

Push hard and deep on the chest

A nurse is assisting a client with a meal. The client suddenly grabs at her neck with both hands and appears frightened. The appropriate nursing action is to

*See if the patient can breathe

A nurse is caring for a client who is 3 days post-op following a cholecystectomy. The nurse suspects a wound infection because the drainage on the dressing is yellow and thick. The nurse identifies this type of drainage as:

*Purulent exudate

A nurse is caring for a client who has a NG tube for intermittent feedings. WOTF actions should the nurse take?

Elevate the pt's HOB 45 degrees before the feeding.

A client is admitted for evaluation and control of HTN. Several hours after the client's admission, the nurse discovers the client supine on the floor, unresponsive to verbal or painful stimuli. The nurse's first reaction at this time is to:

Establish an airway

An older adult client has been hospitalized on bed rest for 1 week. The client reports elbow pain. Which of the following is an appropriate initial action for the nurse caring for this client to take

Examine the elbow

When communicating with a client who is hearing impaired, the nurse should

Face the client and speak slowly

teaching sn about client who has a wound that is healing by secondary intention. WOTF should the SN include in teaching?

Granulation fills the wound during healing.

A client's provider has ordered that sputum specimen be collected for culture and sensitivity. The nurse plans to collect this specimen...

In the morning upon rising.

A nurse is collecting a urine specimen for a client to test via urine dipstick the urine's specific gravity. The nurse knows the result will indicate the amount of:

Solutes in the urine

A Nurse is caring for a client who has a hx of dysrythmias. Upon entering the room, the nurse discovers the client is unresponsive to verbal or painful stimuli, has no respiration and is pulse-less. WOTF actions should the nurse take first?

Start chest compression's

SN is preparing to administer an IM injection to a cleint that is overweight. WOTF sites should the SN Select?

The side hip between the iliac crest and the anterior ilac spine.

SN applying stockings for pt with hx of DVT. WOTFA would SN take when applying the stockings?

Turn inside out up to heel before applying.

A nurse is caring for a client who has just had a mastectomy and has a closed wound suction device (hemovac) in place. Which nursing action will ensure proper operation of the device?

Collapsing the device whenever its 1/2-2/3 full of air.

A client being discharged following abdominal surgery will be performing his own dressing changes at home. It is most important for the nurse to include which of the following in the discharge plan?

Demonstration of appropriate hand hygeine

The mother of a toddler calls the nurse "Help! My baby is choking on his food!" The nurse determines that the heimlich maneuver is necessary based on which finding:

Inability of the toddler to cry or speak

A nurse is administering a cleansing enema to a client who is scheduled for a diagnostic procedure. WOTFA should the nurse take?

Insert the tip of the tubing 8 cm (3.1in)

A nurse is caring for a client who has a new prescription for tube feeding. The nurse understands that the provider prescribed tube feeding because the client:

Is unable to swallow foods by mouth

A nurse has inserted an indwelling catheter for a male patient. Where should the nurse tape the catheter to prevent pressure on the client's urethra?

Lower abdomen

A client who is post-op following laparotomy is reporting pain and dry mouth. The client has morphine sulfate ordered to control the pain. Before administrering the morphine sulfate prescribed for the client the nurse should first

Measure the client's vital signs.

SN Care for client with two Penrose Drains near abdominal incision. WOTF adhearing devices is the best choice for the SN to use to decrease skin irritation?

Mongomery Straps

A client returns from surgery with two penrose drains in place. Anticipating frequent dressing changes, what should the nurse use around the incision site?

Montgomery straps

When a nurse makes an initial assessment of a client who is post-op following gastric resection, the client's NG tube is not draining. The nurse's attempt to irrigate the tube with 10ml 0.9% NaCl was unsuccessful, so she determines that the tube was obstructed. Which of the following actions should the nurse take?

Notify the surgeon.

A nurse is performing an eye irrigation for the client who has been exposed to smoke and ash. Which of the following nursing actions should receive the highest priority during the irrigation?

Wearing gloves during the procedure.

A nurse is caring for a client who is post-op following a partial colectomy. THe patient has a NG tube set on low continuous suction. The client tells his nurse that his throat is sore and asks the nurse when the NG tube will be taken out. Which of the following responses by the nurse is appropriate at this time?

When the GI tract is working again, in about three to five days, the tube can be removed.

SN is reinforcing teaching with a client about colostomy care. WOTF info should SN include in the teaching?

cleanse stoma with warm water.

Nurse is caring for a clients who are receiving O2 therapy

client with heart failure who is recieving 100% o2 on partial re-breather.

SN changing dressing on a client who had abd sx. WOTFA should the SN take?

don clean gloves to remove old dressing.