PNFundamentals A
a nurse is reviewing the medical record of a client who has heart failure. which of the laboratory results suggests fluid volume excess?
BUN 8
a nurse is reinforcing teaching with a client getting PCA. which of the following statements indicates an understanding of the teaching?
" I will not let anyone press the button for me"
a nurse is speaking with a client who had DM II and a prescription for insulin. the client verbalize anger about having to take insulin. which of the following responses should the nurse make"
"I see that you are angry. Let's sit down and talk about it."
a nurse is reinforcing teaching about the use of crutches with a client who has a fractured right tibia and fibula. which of the following statements indicates understanding?
"I will be sure to keep the crutch tips dry"
a nurse is collecting data from a client who is menopausal. which of the following statements indicates that the nurse should screen the client for depression?
"my family doesn't need me anymore. I've failed in so many ways"
a client who had a recent BTK amputation says, "I don't know how I can continue to live my life without my leg." which is the appropriate response?
"tell me what concerns you have about your future"
a nurse is caring for a. client who has metastatic cancer and practices Catholicism. the client asks the nurse to discuss the afterlife with her. which of the following statements by the nurse assists in meeting the client's spiritual needs?
"tell me what the afterlife means to you"
a nurse is reinforcing teaching about hospice measures with a family of a client. which of the following statements indicates an understanding of the teaching?
"we will keep the room cool to help her breathe better"
a nurse is caring for a client who has recently undergone a bilateral mastectomy. which of the following statement by the client requires immediate action by the nurse?
"when I look at myself in the mirror, I don't know if I can go on."
a nurse is reinforcing teaching with a client about the prevention of stress injuries. which of the following instructions should the nurse include?
"when lifting a heavy object, keep it close to your body"
a nurse is caring for a client who is postoperative and experiencing N/V. which of the following findings indicates the client has fluid volume deficit? SATA
-decreased skin turgor -orthostatic hypotension -flat neck veins
a nurse is caring for a disorientated client at high risk for falls. which of the following actions should the nurse take? SATA
-nonskid slippers -room near the nurses station -reinforce call light teaching
intake for a client in 8 hours 150mL/hr IV 120mL juice 500mL water
1820mL
nurse finds a fire. what should she do? RACE
Evacuate clients Pull the fire alarm Close the fire doors Use the fire extinguisher
a client has a bacterial infection and a persistent oral temperature of 38.9 (102). which of the following interventions should the nurse include in the plan of care to treat the fever?
administer acetaminophen
a nurse is planning to perform wound irrigation for a client who has a large abdominal wound. which of the following actions should the nurse plan to take?
administer an analgesic 30 minutes prior to begining
a nurse is reinforcing dietary teaching with a client who has chronic kidney disease and requires a low K+ diet. which of the following food choices by the client demonstrates and understanding
applesauce
a nurse is caring for a female client who has urinary incontinence. which of the following actions should the nurse take?
apply a moisture barrier to the peri area
a nurse is assisting with the plan of care for a client with aphasia following a stroke. which of the following interventions should the nurse use to assist the client with communication?
ask close-ended questions
a nurse is caring for a client who is alert in a LTC facility. which of the following actions should the nurse take to protect the clients privacy?
ask the client before discussing his condition when family is present
a nurse is assisting with the administration of a client who has active TB. which of the following actions should the nurse plan to take?
assign the client to a negative pressure air flow room
a nurse is assisting with the plan of care for 4 clients. which of the following should the nurse assign to the AP?
assist a client to get out of bed after a breathing treatment
a nurse is using Maslow's hierarchy of needs in assisting with discharge planning. which of the following activities is a priority?
attend an exercise program
a nurse is explaining ethics an values to a newly licensed nurse. the nurse should explain that allowing the client to make decisions about treatment is an example of which of the following principles?
autonomy
a nurse is caring for a client with a K+ supplement. the client says the pill is too large to swallow and refuses to take it. the nurse offers to break it into two smaller pieces. which of the following ethics principle was demonstrated?
beneficence
a nurse is preparing to administer an enteral feeding to a client who has an NG tube in place. Which of the following methods should the nurse take to verify placement
check the pH of the aspirate
a nurse is assisting with a presentation to a group of older adults about hypothermia and hyperthermia. which of the following information should the nurse include about age-related changes?
circulation becomes less efficient with age
a nurse is preparing to remove a client's peripheral IV catheter. After performing hand hygiene and applying clean gloves, which of the following actions should the nurse take first?
clamp the infusion tubing
a nurse is contributing to the plan of care for a client 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 pedal pulses bilaterally every 4 hours
a nurse is preparing to administer topical medication to a client. which of the following actions should the nurse take?
compare the label of the medication container with the MAR 3 times
a nurse is assisting with admission of a client who brought her own medication to the facility. which of the following actions should the nurse take?
compare the medication the provider has prescribed with the medications from home
a nurse is caring for a client who is receiving continuous NG tube feedings. the nurse listens to the client's bowel sounds which of the following actions should the nurse take
decrease rate of feeding
a nurse id reinforcing teaching about health promotions with a group of young adults. which information should the nurse include?
dental assessment every 6 months
a nurse is reinforcing teaching with a client about using guided imagery. which of the following actions should the nurse take?
direct the client to visualize tension leaving the body
a nurse is caring for a client refusing medical treatment. which of the following actions should the nurse take?
document the client's refusal of the treatment
a nurse is palpating the pulse located on the top of a client's foot. which of the following pulses should the nurse document she is palpating?
dorsalis pedis
a nurse is caring for a client who has an indwelling urinary catheter. which of the following actions should eh nurse take to prevent UTIs?
drain the urine from the tubing before ambulation
a client has a positive throat culture for streptococci. which intervention should be included in the plan of care?
ensure the client were a surgical mask during transportation through the facility
a nurse is reinforcing teaching with a client who has hearing loss about how to modify his home environment. which of the following is a priority modification that the nurse should include?
flashing smoke alarm
a nurse is reinforcing teaching about carbon monoxide poisoning. which of the following should be included?
headaches are a common manifestation
a nurse is caring for a client who has a NG tube and getting continuous feeding. which of the following actions should the nurse take?
hold the feeding for 2 consecutive gastric residuals greater than 250mL
a nurse is repositioning a client who has quadriplegia and in a supine position. which of the following actions should the nurse take to prevent client musculoskeletal injury?
internally rotate the hips by using the trochanter roll
a client who has advanced cancer tells the nurse that he has a difficult time talking to anyone about the illness. Which of the following actions should the nurse take to encourage therapeutic communication?
le the client know the he is available and willing to listen
a nurse is caring for client with C. diff. which of the following solutions should the nurse use to perform hand hygiene while caring for this client?
mild soap
a nurse is preparing to administer oxygen to a client with HF and severe difficulty breathing. which of the following oxygen delivery equipment should the nurse select to provide the highest concentration of oxygen to the client?
nonrebreather mask
a nurse is contributing to a plan of care for a client with a prescription for a wrist restraint. which actions should be included in the plan?
pad the bony prominences
a nurse in a LTC facility is contributing to the car plan for a client at risk for pressure ulcers. which recommendations should be included in the plan?
perform a thorough skin inspection each day
a nurse is moving a client up in bed with assistance of a second nurse. which pf the following actions should the nurse take?
place feet apart with the foot nearest the HOB in front of the other foot
a nurse is reinforcing teaching with a client who has a prescription for a TENS unit. which information should the nurse include?
place the electrodes near the pain site
a nurse id collecting data from a client who has an NG tube set to low intermittent suction. which of the following findings indicates hypomagnesemia?
positive Chvostek's sign
a nurse is reinforcing teaching with a client about smoking cessation. which of the following is the first stage of health behavior change?
precontemplation
a nurse is reinforcing preoperative teaching with a client who does not speak the same language. which action should the nurse take?
provide handouts written in the client's primary language
a nurse is reviewing the vital sign of 4 clients. which of the following findings requires further data collection by the nurse?
pulse of 110/min
a charge nurse is reinforcing teaching with an AP about performing pulse oximetry. which of the following information should be included in the teaching?
remove polish from the clients fingers before applying
a nurse is reinforcing teaching with a client about oral hygiene. which of the following instructions should the nurse include in the teaching?
replace toothbrush following an illness
a nurse writes client information on a paper while receiving report. how should the nurse dispose of the paper?
shred it
a nurse is reinforcing teaching with a client who reports inability to sleep. which information should the nurse include when teaching about aging and sleep?
sleep patterns change with age
a nurse is providing wound care for a group of clients. which of the following wounds should be identified as healing by secondary intention?
stage 3 pressure ulcer
a nurse is collecting data from an olde client. which of the following finding should the nurse report to the provider?
the client reports urinary incontinence
a nurse has delegated various client care asks to the APs. which of the following actions by the AP should the nurse identify as correct?
wearing a mask ti=o get the vital signs of a client with pertussis