PN Fundamentals Online Practice B

A nurse is caring for a patient and is concerned that the patient may have a fecal impaction. Which of the following is the most important question for the nurse to ask?

"Have you had small liquid stools?"

A nurse is reinforcing teaching about the use of crutches with a patient who has a fractured right tibia and fibula. Which of the following statements by the patient indicates an understanding of the teaching?

"I will be sure to keep the crutch tips dry"

A nurse is assisting with the admission of an older adult to an acute care facility. Which of the following is a therapeutic response the nurse should make?

"describe your concerns about sleeping to me"

A nurse is contributing to the plan of care for a patient who practices Islam. Which of the following questions should the nurse ask the patient to clarify the patient's religious preferences?

"do you consume pork products?"

A nurse is caring for a patient who reports difficulty sleeping at home. Which of the following recommendations should the nurse provide to promote a restful home sleep environment?

"perform muscle relaxation to reduce anxiety and induce sleep"

A nurse is providing care to four patients in an acute care setting. The nurse should identify that which of the following patient statements presents an ethical dilemma?

"please don't tell my doctor, but I am taking my partner's oxycodone"

A nurse is caring for a patient who has a terminal illness and a family member asks why the patient's mouth is continually open. Which of the following responses should the nurse make?

"the reduced muscle tone has relaxed the jaw muscles"

A nurse is reinforcing preoperative teaching with a patient about how to turn, cough, and deep breathe. Which of the following statements by the patient indicates an understanding of the teaching?

"this can help prevent pneumonia"

A nurse is reinforcing teaching with the partner of a patient who is immobile. Which of the following instructions should the nurse give the partner about turning the patient in bed?

"tighten your stomach muscles" *as well as gluteal muscles to help protect their back

A nurse is caring for a patient who is postoperative and is experiencing nausea and vomiting. The nurse should identify which of the following findings as indications that the patient has fluid volume deficit? Select all that apply

- cool extremities - orthostatic hypotension - flat veins

A nurse is assisting in the care of a patient in a medical surgical unit. What findings indicate an improvement in the patient's condition?

- granulation tissue covers the wound bed - no odor present - improved comfort level - decrease in the size of the wound bed

A nurse is contributing to the plan of care for a patient who is dying. Which of the following interventions should the nurse recommend to include in the patient's family in the plan of care?

- keep the family updates about the patient's status - encourage the family to comb the patient's hair - tell the patient's family what to expect as the patient's death nears

A nurse is assisting in the care of a patient who has a continuous enteral feeding. Which three findings should the charge nurse be notified of?

- lung sounds - patient's cough - gastric residual

A nurse in an emergency department (ED) is assisting with the care of a patient. What findings indicate the patient might be malnourished?

- patient is cachectic with flaccid muscle tone - skin is dry and scaly with bruises on extremities -pulse rate 118/min - abdomen is distended - BMI 17

A nurse is admitting a client and reviewing their medical record. Which of the following actions should the nurse take?

- place the patient in droplet isolation precautions - apply oxygen at 2 L/min via nasal cannula - request a prescription for an antipyretic med - stay at least 0.9 m (3 feet) away from patient when possible

A nurse is assisting with the admission of a patient who reports experiencing a sore throat, productive cough, and fever for the past 3 days. The nurse is collecting data from the patient's medical record. Which of the following interventions should the nurse expect? Select all that apply

- request a prescription for an antibiotic med - initiate droplet precautions - wear a mask within 1 m (3 feet) of the patient - apply a mask on the patient when the patient leaves their room

A nurse is caring for a patient who has a peripheral IV inserted for fluid replacement. A nurse is collecting data from the patient. Which of the following actions should the nurse take?

- stop the infusion dressing - elevate the patient's left arm - apply heat to the patient's left hand

A nurse is caring for a group of patients in a long-term care facility. Which of the following action should the nurse take to prevent health care-associated infections for these patients?

- wash hands after removing gloves - use antimicrobial hand gel after refilling a patient's water pitcher - clean the stethoscope with an antimicrobial wipe after obtaining vital signs

A nurse is reinforcing teaching with a patient who has chronic kidney disease and requires a low-potassium diet. Which of the following choices by the patient demonstrates an understanding of the teaching?

1 cup of applesauce

A charge nurse smells smoke, enters the visitor restroom, and sees flames in the trash can. What is the sequence of actions that the nurse should take?

1. evacuate the patients from the area 2. pull the level on the fire alarm box 3. close the fire doors on the unit 4. use a fire extinguisher to put out the fire

A nurse is assisting in the care of a patient who has pancreatitis. Select 3 tasks the nurse should delegate to an assistive personnel (AP)

1. measure the patient's intake and output 2. Document the patient's vital signs 3. Transfer the patient from a wheelchair to the bed

A nurse is preparing to administer a med to a preschooler and must convert the child's weight from pounds to kilograms. The child weighs 30 pounds. How many kilograms does the child weigh? *round to the nearest tenth

13.6 kg

A nurse is preparing to document information about a patient's lower legs, which are swollen with 6 mm edema. Which of the following information should the nurse document?

3+ pitting edema

A nurse is reviewing the medical record of a female patient who has heart failure. The nurse should identify which of the following lab results as an indication that the patient has fluid volume excess.

BUN 8 mg/dL (10 to 20 mg/dL) *with fluid volume excess, the nurse should expect the patient's BUN to be below the expected reference range due to hemodilution

A nurse is contributing to the plan of care for a patient who has a prescription for elastic bandages to the lower extremities. Which of the following actions should the nurse recommend for the plan of care?

Compare the patient's pedal pulses bilaterally every 4 hours

A nurse is caring for a patient who has chronic kidney disease. The nurse should identify that which of the following findings is the priority to report to the provider?

The patient's output was 60 mL for the past 3 hours *this represents oliguria and can indicate a decrease in kidney perfusion or function

A nurse is collecting data from a patient who is 2 days postop following a colostomy placement. Which of the following findings should the nurse report to the provider?

a purple colored stoma

A nurse is caring for a patient who is postop following a mastectomy. The patient states "I can barely look at myself in the mirror". The nurse should identify the patient is experiencing which of the following?

actual loss *actual loss is a loss that occurs when the person can no longer feel, see, hear, or know an object, another person, or a part of themselves, such as the loss of a body part

A nurse is planning to perform wound irrigation for a patient who has a large abdominal wound. Which of the following actions should the nurse plan to take?

administer an analgesic 30 min before starting the procedure

A nurse is assisting with the care of a patient who is receiving a unit of packed RBCs The patient has manifestations of ____ as evidenced by the patient's _____-

allergic reaction, itching

A nurse is caring for a postop patient who is at risk of thrombus formation. Which of the following interventions should the nurse delegate to an AP?

apply thromboembolic stockings

A nurse is assisting with the plan of care for a patient who has aphasia following a stroke. Which of the following interventions should the nurse use to assist the patient with communication?

ask the patient close-ended questions

A nurse is assisting with the plan of care for four adults. Which of the following tasks should the nurse assign to an assistive personnel?

assist a patient to get out of bed after a breathing treatment

A nurse is caring for a patient who has a prescription for a potassium supplement. The patient tells the nurse that the pill is too large to swallow and refuses to take it. The nurse offers to break the pill into two smaller pieces. The nurse is demonstrating which of the following ethical principles?

beneficence *the nurse is demonstrating beneficence by acting in the patient's best interest to make it possible for the patient to swallow the med

A nurse is preparing to administer an enteral feeding to a patient who has an NG tube in place. Which of the following methods should the nurse use to verify correct placement of the NG tube?

check the gastric pH of the gastric aspirate

A nurse is a long-term care facility is collecting admission data from a patient who uses a hearing aid. Which of the following actions should the nurse take?

choose a private room for the interview

A nurse is assisting with the admission of a patient who has brought their meds to the facility. Which of the following actions should the nurse take?

compare the meds the provider has prescribed with the patient's meds from home

A nurse is checking for a patient's pulse deficit after detecting an irregular heart rate. Which of the following actions should the nurse take?

count the patient's radial and apical pulses simultaneously with another nurse

A nurse has delegated various patient tasks to the AP on the care team. Which of the following actions by the AP should the nurse identify as correct?

donning a mask to measure the vital signs of a patient who has pertussis *requires droplet precautions, so they should be wearing a mask within 1 m or 3.3 ft of the patient

A nurse is preparing to palpate a patient's pulse. The nurse should recognize that which of the following pulses is located on the top of the patient's foot?

dorsalis pedis

A nurse in a community clinic is talking with an older adult patient who states that their life has no purpose. The nurse should identify that the patient is in which of the following stages of Erikson's Theory of Psychosocial Development?

ego integrity vs. despair

A nurse is contributing to the plan of care for a patient who has a positive throat culture for streptococci. Which of the following interventions should the nurse recommend to be included in the plan of care?

ensure that the patient wears a surgical mask during transportation throughout the facility

A nurse is caring for a patient who has chronic pain. The nurse recommends that the patient concentrate on a memory of a pleasurable experience. Which of the following complementary therapies is the nurse suggesting?

guided imagery

A nurse is repositioning a patient who has quadriplegia and is in the supine position. Which of the following actions should the nurse take to prevent patient musculoskeletal injury?

internally rotate the patient's hips by using a trochanter roll

A nurse is assisting with the care of a patient who has a prescription for IV therapy. The patient tells the nurse they have numerous allergies. Which of the following allergies should the nurse bring to the attention of the charge nurse prior to the initiation of the therapy?

latex

A nurse is contributing to the plan of care for four patients. For which of the following patients should the nurse initiate airborne precautions?

measles * pneumonia = droplet * pertussis = droplet * MRSA = contact

A patient who is scheduled to undergo surgery tells the nurse that they do not understand the procedure and are reconsidering their decision to have it. Which of the following actions should the nurse take?

notify the charge nurse of the patient's concerns

A nurse is contributing to a plan of care for a patient who has a new prescription for a wrist restraint. Which of the following actions should the nurse take?

pad bony prominences on the wrist

A nurse is assisting with the admission of a patient to a medical-surgical unit. Which of the following findings should the nurse identify as an indication that the patient is malnourished?

pallor with scaly skin

A nurse is planning to perform intermittent urinary catheterization for a patient who is unable to urinate. Which of the following actions should the nurse take first?

perform a bladder scan *first step = collecting data from patient. therefore, the nurse should evaluate the bladder contents before performing an invasive procedure

A nurse is planning care for a group of patients. The nurse should expect to witness an informed consent for a patient who will undergo which of the following procedures?

performance of a paracentesis

A nurse is collecting data from a patient who has an NG tube set to low intermittent suction. Which of the following findings indicate hypomagnesemia?

positive Chvostek's sign *to elicit this, the nurse should tap the patient's facial nerve near the ear. If the facial muscles contract, the sign is positive, indicating low serum magnesium or calcium levels

A nurse is caring for a patient who has a new diagnosis of cancer. Which of the following actions by the nurse maintains the patient's confidentiality?

providing patient information to another nurse at the change of shift

A nurse in an acute care setting is documenting postmortem care in a patient's medical record. Which of the following information should the nurse include in the documentation?

release of personal belongings form

A nurse in an emergency department is caring for a patient. The nurse should first ____ followed by _____

review the medications that may be causing the patient's confusion, using alternative methods to keep the patient safe

A nurse at a long-term care facility is caring for a patient who is alert. Which of the following actions should the nurse take to protect the patient's privacy?

speak with the patient about their condition after visitors have left

A nurse is reinforcing teaching with a patient about the use of crutches. Which of the following actions by the patient indicates an understanding of the teaching?

the patient advances the unaffected leg first while climbing stairs

A nurse is caring for a patient who has just died and practiced Islamic faith. Which of the following cultural practices should the nurse expect?

the patient's face should be turned toward Mecca

A nurse is preparing to obtain a patient's vital signs. Which of the following actions should the nurse take when washing their hands?

turn off the faucet with a clean paper towel after drying hands

A nurse is reinforcing teaching about health promotion with a group of young adult patients. Which of the following information should the nurse include?

young adults should have a dental assessment