Practice Test for Fundamentals

b.) dignity

A nurse pulls the curtains before changing the dressing of the surgical would on the abdomen of a post-surgical client. a.) accountability b.) dignity c.) freedom d.) altruism

d.) clear breath sounds

After suctioning a client, a nurse should expect to find: a.) respiratory rate of 28 breaths/minute b.) a heart rate of 104 beats/minutes c.) brisk capillary refill d.) clear breath sounds

d.) Tachypnea

During assessment, a nurse measures a clients respiratory rate at 32 breathes/minute with a regular rhythm. When documenting this pattern, the nurse should use which term? a.) eupnea b.) bradypnea c.) apnea d.) tachypnea

c.) practicing hand hygiene

Of all possible nursing interventions to break the chain of infection, which is the most effective? a.) administering medications b.) providing good skin care c.) practicing hand hygiene d.) wearing gloves at all times

c.) invasion of privacy

The student nurse tells her family about a client AIDS cared for in clinical yesterday. Which tort has student committed? a.) slander b.) assault c.) invasion of privacy d.) fraud

d.) a client with low back pain

Which client would benefit from the application of warm moist heat? a.) a client with appendicitis b.) a client with a recently sprained joint c.) a client with a suspected malignancy d.) a client with low back pain

c.) a patient's face is contorted with pain

Which of the following is an example of nonverbal communication? a.) a nurse says, "I am going to help you walk now." b.) a nurse presents information to a group of patients c.) a patient's face is contorted with pain d.) a patient asks the nurse for a pain shot

a.) supine

The nurse understands that client position is important when treating dyspnea. What position would be contraindicated for a client who has dyspnea? a.) supine b.) contour c.) fowlers d.) orthopneic

b.) stop the feedings and check for residual volume

A client complains of abdominal discomfort and nausea while receiving tube feedings. Which intervention is most appropriate for this problem? a.) give the feedings at room temperature b.) stop the feedings and check for residual volume c.) place the client in semi-fowler's position while feeding d.) change the feeding container daily

b.) sodium

A nurse is reviewing a client's laboratory test results. Which electrolyte is the major cation controlling a client's extracellular fluid (EFC) osmolality? a.) potassium b.) sodium c.) chloride d.) calcium

a.) encourage the client to ambulate

As the nurse assists the postoperative client out of bed, the client reports having gas pains in the abdomen. To reduce this discomfort, what should the nurse do? a.) encourage the client to ambulate b.) insert a rectal tube c.) insert a NG tube d.) encourage the client to drink carbonated liquids

a.) integrity

In the delivery of care, the nurse acts in accordance with nursing standards and the code of ethics and reports a medication error that she has made. The nurse is most clearly demonstrating which of the following professional values? a.) integrity b.) altruism c.) social justice d.) human dignity

d.) the granulation tissue is at the wound edges

For healing by secondary intention, a client's would has been packed with medicated dressings. The nurse assesses the wound. Which finding indicated would healing? a.) the tissue surrounding the wound is red and hot b.) the would drainage is serous c.) the skin around the wound is edematous d.) the granulation tissue is at the wound edges

b.) constipation and hard stool

Ignoring the urge to defecate on a continual basis leads to a.) sudden increase in stool with mucus b.) constipation and hard stool c.) need to increase milk intake d.) total loss of bowel control

c.) assault

The charge nurse overhears a staff nurse threatening to restrain a verbally abusive client if the abuse continues. The charge nurse meets with the staff nurse to discuss this behavior. Which legal tort, if identified by the charge nurse, would alert the staff nurse to potential criminal charges? a.) invasion of privacy b.) negligence c.) assault d.) defamation of character

c.) apply a water soluble lubricant to the nares

The client has sore nares while a NG tube is in place. Which nursing measure would be most appropriate to help alleviate the client's discomfort? a.) reposition the tube in the nares b.) irrigate the tube with a cool solution c.) apply a water soluble lubricant to the nares d.) have the client change position more frequently

b.) teach the patient to perform pelvic floor muscle excercises

The clinic nurse is preparing a plan of care for a patient with a history of stress incontinence. What role will the nurse have in implementing a behavioral therapy approach? a.) provide medication teaching related to pseudoephedrine sulfate b.)teach the patient to perform pelvic floor muscle exercises c.) prepare the patient for an anterior vaginal repair procedure d.) provide information on periurethral bulking

d.) provide for an aseptic environment to prevent infection

The family cannot go with the surgical client past the doors that separate the public from the restricted area of the operating room suite. These measures are designed to: a.) protect the privacy of clients b.) prevent electrical sparks that could ignite the anesthetic gases c.) separate the family from the surgical team while they are working on the client d.) provide for an aseptic environment to prevent infection

c.) improved circulation to the area

The nurse applies warm compresses to a clients leg. To determine effectiveness of the compresses, the nurse should determine if there is: a.) less scaling on the skin b.) decreased bruising c.) improved circulation to the area d.) decreased swelling in the area

c.) when the oral cavity has thick secretions

The nurse places the above catheter at the client's bedside for use at which time? a.) when the tracheostomy becomes obstructed b.) During an ostomy irrigation c.) when the oral cavity has thick secretions d.) following a nasal surgery

c.) minimize urinary catheter use and duration of use in all clients

To reduce the possibility of catheter-related urinary tract infections (CAUTIs), the nurse should: a.) use sterile technique when providing catheter care b.) ensure that clients who are incontinent have indwelling urinary catheters c.) minimize urinary catheter use and duration of use in all clients d.) clean the periurethral area with antiseptics

a.) the client should begin coughing and deep breathing exercises as soon as he's able to follow instructions

A client is scheduled for an appendectomy. What is the nurse's highest priority when planning preoperative teaching for this client? a.) the client should begin coughing and deep breathing exercises as soon as he's able to follow instructions b.) surgical would infection is most likely to occur during the first postoperative day c.) the client should be encouraged to take food and fluids to prevent dehydration and malnutrition d.) the clients skin should be assessed hourly

b.) slander

A client on a surgical unit asks for the nurses opinion of the surgeon. The nurse replies, "He is rude. His patients always end up with infections." The nurse is at risk of being accused of which of the following? a.) libel b.) slander c.) negligence d.) assault

c.) placing the client in high fowler's position

A client tells the nurse he is experiencing dyspnea. Which action by the nurse is most appropriate? a.) placing the client in Trendelenburg position b.) placing the client in Sims' position c.) placing the client in high fowler's position d.) placing the client in the supine position

b.) Your mother might get dizzy when she gets up so she needs to sit on the side of the bed first

A Client has been bedridden for a week. The daughter of the client asks the nurse why her mother needs to sit on the bedside before getting out of bed. The nurses best response is: a.) we will be walking all the way down the hall so we need to take a break before getting out of bed? b.)Your mother might get dizzy when she gets up so she needs to sit on the side of the bed first c.) I need to put on her slippers before she gets up to walk so she wont sleep when she walks d.) we need to let your mother catch her breath before she gets out of bed

c, d, e

A client has a cast applied to the left leg after sustaining a femur fracture during a skiing accident. Which interventions would the nurse provide to avoid complications from the cast application? Select all that apply a.) apply warm compresses to the casted leg b.) bivalving the cast on both sides c.) monitor distal pulses of the affected extremity d.) maintain the leg elevated above the level of the heart e.) administer anticoagulation per healthcare providers order

c.) The catheter bag is placed upon the client's lap for safe transport

A client has an indwelling urinary catheter and is prescribed physical therapy. As the client is being placed in a wheelchair, which action by the assistance would need further clarification by the nurse? a.) the catheter drainage bag is placed on the lower side of the wheelchair b.) the assistant brings a container to drain the urine from the bag c.) the catheter bag is placed upon the client's lap for safe transport d.) the assistant checks to make sure the tubing is not kinked

a.) imbalanced nutrition, less than body requirements

A client has been on a clear liquid diet for 5 days. What is an appropriate nursing diagnosis for this client? a.) imbalanced nutrition, less than body requirements b.) risk for injury c.) fluid volume deficit d.) activity intolerance

d.) assist the client up to the toilet to attempt to void

A client has been unable to void since having abdominal surgery 7 hours ago. The nurse should first: a.) encourage the client to increase oral fluid intake b.) insert an intermittent urinary catheter c.) notify the health care provider (HCP) d.) assist the client up to the toilet to attempt to void

b.) "oil retention enemas soften stool, and cleansing enemas stimulate a bowel movement."

A client has orders for an oil retention enemas and a cleansing enema. The client asks the nurse to explain the purpose of the enemas. Which of the following is the most accurate response by the nurse? a.) "You seem to have a lot of trouble with constipation and these will help." b.) "oil retention enemas soften stool, and cleansing enemas stimulate a bowel movement." c.) "The cleansing enema is given first so that the oil retention enema can do its job." d.) "Two enemas are very effective in preventing a reoccurrence of constipation."

c.) decompression

A client is recovering from abdominal surgery and has a NG tube inserted. The expected outcome of using the NG tube is gastrointestinal tract: a.) compression b.) lavage c.) decompression d.) gavage

d.) the patient

A competent adult patient is scheduled for surgery. Who signs the informed consent form to allow the surgery? a.) a relative b.) the physician c.) a nurse d.) the patient

d.) palpate the brachial artery and then place the arrow on the cuff over the palpated artery

A nurse needs to obtain an accurate blood pressure on a client. Which of the following is the most important action for the nurse to take to ensure an accurate reading? a.) encourage the client to make a fist several times before taking the blood pressure b.) raise the client's arm above the level of the heart prior to taking the blood pressure c.) have the client lie in a supine position while the blood pressure is taken d.)palpate the brachial artery and then place the arrow on the cuff over the palpated artery

b.) the nurse uses a rocking motion while helping the client to stand

A nurse prepares to transfer a client from a bed to a chair. Which principle demonstrates safe body mechanics? a.) the nurse stands an arms length from the client b.) the nurse uses a rocking motion while helping the client to stand c.) the nurse keeps her knees straight and stiff and bends at the waist d.) the nurse keeps her feet as close together as possible

c.) implementing

Based on an established plan of care, a nurse turns a patient every 2 hours. What part of the nursing process is the nurse using? a.) assessing b.) planning c.) implementing d.) evaluating

c.) identification bracelet

On admission to the same-day surgery, the nurse reviews the medical record to verify the client's identification documentation. Which information is most important? a.) admitting record b.) preprinted labels c.) identification bracelet d.) location of family

a.) illness prevention

The nurse is administering immunizations to a group of teens in a county health clinic. The nurse correctly identifies this action as: a.) illness prevention b.) restorative care c.) treatment of disease d.) supportive nursing care

b.) perform a systematic skin assessment at least once a day

What should the nurse do to prevent pressure ulcers in an older adult? a.) clean the skin daily using mild soap and hot water b.) perform a systematic skin assessment at least once a day c.) massage bony prominences gently every shift d.) encourage the client to sit in a chair as much as possible

b.) 2" (5cm)

When placing an indwelling urinary catheter in a female client, the nurse should advance the catheter how far into the urethrae? a.) 1/2" (1 cm) b.) 2" (5 cm) c.) 6" (15 cm) d.) 8" (20 cm)

b.) obtain a chest x-ray and measure the pH of stomach contents

Which of the following is the recommended nursing assessment to confirm placement of the NG tube into the stomach of a client? a.) NG tube length is equal to the distance from the client's ear lobe to the nose, plus the distance from the nose to the tip of the xiphoid process; this will confirm correct placement b.) obtain a chest x-ray and measure the pH of stomach contents c.) measure to the second or third black marking on the NG tube d.) apply the stethoscope to the xiphoid process and instill 50 mL of the air into the tube and listen for a gurgling or popping sound

a.) assisting a patient with ambulation

Which of the following nursing care tasks is acceptable for a graduate nurse to delegate to unlicensed assistive personnel (UAP)? a.) assisting a patient with ambulation b.) evaluation of nursing care delivered to a patient c.) initial and ongoing assessments d.) development of a patient teaching plan

b.) breath sounds clear on auscultation

Which outcome criterion would be most appropriate for a client with a nursing diagnosis of ineffective airway clearance? a.) presence of congestion on xray b.) breath sounds clear on auscultation c.) continued use of oxygen when necessary d.) respiratory rate of 28 breaths/minute

b.) sliding the client to move up in bed

Which positioning technique is not appropriate when the nurse changes a client's position in bed if the client has hemiparalysis? a.) rolling the client onto the side b.) sliding the client to move up in bed c.) lifting the client when moving the client up in bed d.) having the client help lift off the bed using a trapeze

b.) the healthcare team is discussing a client's care during a formal care conference

Which scenario below complies with the HIPPA (Canadian Privacy Act and Personal Information Protection and Electronic Documents Act) regulations? a.) two nurses in the cafeteria are discussing a client's condition b.) the healthcare team is discussing a client's care during a formal care conference c.) a nurse checks the computer for the laboratory results of a neighbor who has been admitted to another floor d.) a nurse talks with her spouse about a client's condition

a.) a cane with four prongs on the end (quad cane)

Which type of mobility aids would be most appropriate for a client who has poor balance? a.) a cane with four prongs on the end (quad cane) b.) a single-ended can with a half-circle c.) a single-ended cane with a straight handle d.) axillary crutches

b.) the right of confidentiality is essential to protect each client's private information

While working in an institution that uses computer documentation, the nurse understands the need to log out of the computer if it is not in use. Following this procedure is necessary because of what ethical problem in nursing? a.) maintaining trust between client and nurse is necessary for proper client care b.) the right of confidentiality is essential to protect each client's private information c.) respect for clients ensures that nurses trat them in a such a way that enables clients to make choices d.) nonmaleficence is the duty not in inflict harm on a client

c.) red, warm, swollen, tender incision with foul drainage

A nurse is assessing a client 2 days after surgery for infection. Which sign or symptom is most indicative of infection? a.) the presence of pain at the incision site b.) rectal temperature of 100 F (37.8 C) c.) red, warm, swollen, tender incision with foul drainage d.) white blood cell (WBC) count of 8,000

b.) "I will report any signs of redness or drainage when I change the dressing."

A nurse has completed discharge teaching for a client, which involves instructions for changing a leg dressing. Which statement would indicate that the teaching has been effective? a.) "I should change this dressing once a week when it starts to hurt." b.) "I will report any signs of redness or drainage when I change the dressing." c.) "The dressing should be changed next time I have an appointment with my physician." d.) "I don't need to worry about this dressing because the home health nurse will change it."

a.) slander

A nurse is overheard in the hospital cafeteria making false comments about a client. The nurse is guilty of: a.) slander b.) libel c.) invasion of privacy d.) assault

a.) wash her hands

When changing a sterile surgical dressing, a nurse first must: a.) wash her hands b.) put on sterile gloves c.) remove the old dressing while wearing clean gloves d.) open sterile packages and moisten the dressings with sterile saline solution

c.) prevent thrombophlebitis and blood clot formation

After a myocardial infarction, the hospitalized client is taught to move the legs while resting in bed. What is the expected outcome of this exercise? a.) prepare the client for ambulation b.) promote urinary and intestinal elimination c.) prevent thrombophlebitis and blood clot formation d.) decrease the likelihood of pressure ulcer formation

c.) being licensed by the State Board of Nursing

After graduation from an accredited program in nursing and successfully passing the NCLEX, what gives the nurse a legal right to practice? a.) enrolling in an advanced degree position b.) filing NCLEX results in the county of residence c.) being licensed by the State Board of Nursing d.) having a signed letter confirming graduation

d.) negligence

An elderly client has been admitted to the medical-surgical unit from the post anesthesia care unit. While the nurse is of the floor, the client falls out of bed and fractures his right leg and right wrist. The nurse finding him states, "The side rails were down and the bed was in the high position." The client's family files legal charges against the nurse and the hospital. Which charge most accurately reflects the nurse's actions? a.) collective liability b.) comparative negligence c.) battery d.) negligence

a.) polyunsaturated fat

The nurse should instruct a client with heart disease to avoid which foods that contribute to increases in serum cholesterol? a.) polyunsaturated fat b.) saturated fat c.) monounsaturated fat d.) phospholipids

c.) oral temperature of 101 F (38.3 C)

Which assessment is most supportive of the nursing diagnosis, impaired skin integrity related to purulent inflammation of dermal layers as evidenced by purulent drainage and erythema? a.) a heart rate of 88 beats/minute b.) wound healing by primary intention c.) oral temperature of 101 F (38.3 C) d.) dry and intact wound dressing

c.) patients-centered, systematic, outcomes-oriented

Which of the following group of terms best describes the nursing process a.) nursing goals, medical terminology, linear b.) nurse-centered, single focus, blended skills c.) patients-centered, systematic, outcomes-oriented d.) having a signed letter confirming graduation

a.) pain

Which of the following is considered the "fifth vital sign"? a.) pain b.) speech c.) strength d.) posture

b.) the client becomes a cyanotic as the NG tube is inserted

A clinical educator is discussing NG tube insertion with a new graduate nurse. What information demonstrates understanding by the graduate nurse to stop, if the client is experiencing difficulty during the procedure? a.) initial choking when the tube is placed in the client's nare is normal b.) the client becomes a cyanotic as the NG tube is inserted c.) the client's face becomes flushed during the procedure d.) the client gags after insertion of the NG tube

a.) clear the clients airway

A hospitalized client who has a living will is being fed through a NG tube. During a bolus feeding, the client vomits and begins chocking. Which action should the nurse take? a.) clear the clients airway b.) make the client comfortable as specified in the clients living will c.) start cardiopulmonary resuscitation d.) stop the feeding and remove the NG tube as specified in the clients living will

a.) keeping the perineal area clean and dry

A client who's dehydrated has urinary incontinence and excoriation in the perineal area. Which action would be a priority? a.) keeping the perineal area clean and dry b.) offering the client the urinal every 3 hours c.) maintaining a fluid intake of 1 L/day d.) applying moist, warm compresses to the client's groin

a.) Check the patency and amount of drainage from the NG tube

A client with a NG tube who is 2 days postoperative bowel resection is reporting increased abdominal pain and nausea. Which assessments or actions by the nurse would be most appropriate? a.) Check the patency and amount of drainage from the NG tube b.) administer an analgesic and antiemetic as ordered c.) irrigate the NG tube with water and give an analgesic as ordered d.) explain that nausea is common because the NG tube irritates the gag reflex

c.) the nurse is protected by the good Samaritan act, which states the nurse may give emergency care using good judgment

A nurse comes across a screaming child in the park. The child was hit by a baseball bat, resulting in a swollen and reddened left arm. Any attempt to move the child's left arm results in the child screaming intensely. The nurse used two baseball bats to make a spilt, which she applied to the child's left arm. The child is transported to the hospital and later develops compartmental syndrome of the left arm. The nurse requests a meeting with the nurse attorney to discuss the possibility of being involved in a litigious suit by the child's family. After a review of the events, which important information will the attorney share with the nurse concerning the case? a.) the nurse was negligent because the client developed compartmental syndrome because of her treatment at the scene b.) the nurse should have waited for help because the good samaritan act states the nurse is not obligated to assist c.) the nurse is protected by the good Samaritan act, which states the nurse may give emergency care using good judgment d.) the nurse does not fall under the good Samaritan act because it is apparent she was negligent in the care she rendered.

d.) criminal

A nurse is arrested for possession of illegal drugs. What kind of law is involved with this type of activity? a.) civil b.) private c.) public d.) criminal

a.) gait and balance information

A nurse is assessing a client for the risk of falls. The nurse should obtain: a.) gait and balance information b.) the facility's restraint policy c.) the family's psychosocial history d.) the client's level of activity at home

c.) tort

A nurse is caring for a client who has undergone coronary angioplasty. The cardiac monitor is showing abnormal ECG waves, indicating arterial fibrillation. The nurse does not recognize the importance of the sign; as a result, the client's condition deteriorates and the client has to be taken up for an emergency procedure. Which of the following describes the nurses legal liability? a.) felony b.) defamation c.) tort d.) slander

a.) aspirate urine from the tubing port, using a sterile syringe and needle

A nurse is obtaining a sterile urine specimen from a client's indwelling urinary catheter. During the procedure, the nurse should: a.) aspirate urine from the tubing port, using a sterile syringe and needle b.) disconnect the catheter from the tubing and collect urine c.) open the drainage bag and pour out some urine d.) wear sterile gloves when collecting urine

b.) pouring solution onto a sterile filed cloth

A nurse is performing a sterile dressing change. Which action contaminates the sterile field? a.) holding sterile objects above the waist b.) pouring solution onto a sterile filed cloth c.) leaving a 1" (2.5cm) edge around the sterile filed d.) opening the outermost flap of a sterile package away from the body

d.) clean the area around the drain moving away from the drain

A nurse is providing would care to a client 1 day following an appendectomy. A drain was inserted into the incisional site during surgery. When providing wound care, the nurse should: a.) remove the dressing and leave the incision open to air b.) remove the drain if would drainage is minimal c.) gently irrigate the drain to remove exudate d.) clean the area around the drain moving away from the drain

b.) help the client dangle his legs

A nurse is transferring a client from the bed to a chair. Which action should the nurse take during this client transfer? a.) position the head of the bed flat b.) help the client dangle his legs c.) stand behind the client d.) place the chair facing away from the bed

b.) the LPN pours the urine into a graduated measuring container

A nurse observes an LPN measuring a client's urine output from an indwelling catheter drainage bag. Which observation by the nurse ensures that the client's urine has been measured accurately? a.) the LPN holds the foley drainage bag up to eye level b.) the LPN pours the urine into a graduated measuring container c.) the LPN uses the measuring markings on the foley drainage bag d.) The LPN pours urine into a paper cup that holds approximately 250 mL

b.) fraud

A nurse who obtains a license to practice nursing by misrepresenting him or herself is guilty of what tort? a.) slander b.) fraud c.) libel d.) assault

d.) an 86-year-old who is bedfast

A nurse working in long-term care is assessing residents at risk for the development of a decubitus ulcer. Which one would be most at risk? a.) an 83-year-old who is mobile b.) a 92-year-old who uses a walker c.) a 75-year-old who uses a cane d.) an 86-year-old who is bedfast

c.) I.V catheter insertion

A nursing instructor is instructing group of new nursing students. The instructor reviews that surgical asepsis will be used for which of the following procedures? a.) instilling eye drops b.) NG tube irrigation c.) I.V catheter insertion d.) colostomy irrigation

d.) jell-o, carbonated beverages, apple juice

A patient has been prescribed a clear liquid diet. What food or fluids will be served? a.) milk, frozen dessert, egg substitutes b.) high-calorie, high protein supplements c.) hot cereals, ice cream, chocolate milk d.) jell-o, carbonated beverages, apple juice

a.) sitting upright, leaning forward slightly

A patient with emphysema is experiencing shortness of breath. To relieve this patient's symptoms, the nurse should assist her into what position? a.) sitting upright, leaning forward slightly b.) low fowler's with the neck slightly hyperextended c.) prone d.) trendelenburg

d.) clients level of consciousness

A physician has ordered a heating pad for an elderly clients lower back pain. Which item would be most important for a nurse to assess before applying the heating pad? a.) clients risk for falls b.) clients vital signs and breath sounds c.) clients nutritional status d.) clients level of consciousness

a.) continue to monitor and record hourly urine output

A physician orders hourly urine output measurement for a postoperative client with an indwelling catheter. The nurse records the following amounts of output for 2 consecutive hours: 8 a.m. (0800): 50 mL; 9 a.m. (0900): 60 mL. Based on these amounts, which action should the nurse take? a.) continue to monitor and record hourly urine output b.) notify the physician c.) irrigate the indwelling urinary catheter d.) increase the I.V. fluid infusion rate

a.) informed consent

A surgeon and nurse meet with their client to discuss what is involved in proposed knee replacement surgery. They describe the procedure, potential risks and benefits, the expected outcome, and consequences if the surgery is delayed or not performed. After listening and asking a few questions, the client signs a form indicating that he agrees to the surgery. What does his signature on the form represent? a.) informed consent b.) durable power of attorney c.) advance directive d.) waiver of rights to file a malpractice suit

d.) oxygen saturation levels of 95% and diaphragmatic breathing patterns

Which of the following assessment factors would indicate a needs for oropharyngeal suctioning? a.) thin sputum, weak cough, and enlargement of the tonsils b.) breathing rate of 36 breaths/min and noisy, gurgling respirations c.) auscultation of crackles in the lower lobes of the lungs d.) oxygen saturation levels of 95% and diaphragmatic breathing patterns

c.) allow the client to rest for a few minutes, then re-assess

The client has just returned to bed following the first ambulation since abdominal surgery. The clients heart rate and blood pressure are slightly elevated; oxygen saturation is 91% on room air. The client reports being "a little short of breath," but does not have dizziness or pain. The nurse should first: a.) obtain a 12-lead ECG b.) administer pain medication c.) allow the client to rest for a few minutes, then re-assess d.) request new activity prescriptions from the health care provider (HCP)

a.) eliminating home safety hazards

The nurse has done fall prevention teaching with the family of a client who is being discharged home. Which of the following actions by the client and family indicates that the teaching has been effective? a.) eliminating home safety hazards b.) encouraging an exercise regimen to strengthen muscles c.) maintaining medication administration at regular times throughout the day, unless the client is sleeping d.) ensuring adequate nutrition, including tea and complex carbohydrate

d.) hypernatremia

The nurse is assessing a client who is restless and agitated, has dry mucous membranes, and has intense thirst. The nurse should assess the client further for which electrolyte imbalance? a.) hypokalemia b.) hypercalcemia c.) hypomagnesemia d.) hypernatremia

d.) turn the client every 2 hours, and encourage coughing and deep breathing

The nurse is caring for an elderly client with a fractured hip who is on bed rest. Which nursing interventions would be included on the plan of care? a.) encourage coughing and deep breathing, and limit fluid intake b.) provide only passive range of motion (ROM), and decrease stimulation c.) have the client lie as still as possible, and give adequate pain medication d.) turn the client every 2 hours, and encourage coughing and deep breathing

a, c, e

The nurse is caring for an elderly client with a possible diagnosis of pneumonia who has just been admitted to the hospital. The client is slightly confused and is experiencing difficulty breathing. Which activities would be appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP)? Select all that apply a.) obtain vital signs b.) initiate oxygen therapy as needed c.) apply anti embolic stockings d.) assess the clients breath sounds e.) keep the client oriented

c.) moisten the dressing with sterile normal saline solution, and then remove it

The nurse is changing the dressing of a client after an abdominal hysterectomy. If the dressing adheres to the client's incisional area, what should the nurse do? a.) pull off the dressing quickly, and then apply slight pressure over the area b.) lift an easily moved portion of the dressing, and then remove it slowly c.) moisten the dressing with sterile normal saline solution, and then remove it d.) remove part of the dressing, and then remove the remainder gradually over a period of several minutes

d.) area around the wound is tender to touch

The nurse is documenting the assessment of a wound on a clients foot. Which of the following assessments would be included as subjective data? a.) temperature is 100.4 degrees F (38 degrees C) b.) area around the wound is pink and swollen c.) drainage from the wound is yellow d.) area around the wound is tender to touch

d.) request that the transporter bring a different cart with a functional clasp

The nurse notices that a cart being used to transport a client has a nonfunctioning clasp on the safety belt. The nurse should: a.) call the safety/Security Department to report the problem b.) use a draw sheet to secure the client during transport c.) contact the Clinical Engineering Department to repair the clasp d.) request that the transporter bring a different cart with a functional clasp

d.) "I will note on your chart that you prefer oral care after meals"

The nurse offers a client items to perform oral care before breakfast. The client refuses the care, stating, "I prefer to brush my teeth my meal." Which of the following statements by the nurse is most appropriate? a.) "It is our unit policy that oral hygiene be performed before meals." b.) "There won't be anyone to assist you after the meal is completed." c.) "I am sure you will feel better if you brush your teeth now." d.) "I will note on your chart that you prefer oral care after meals."

c.) "client verbalized to the nurse the steps to follow if wound becomes red and warm"

The nurse provides teaching on postoperative wound care to a client being discharged from a surgical unit. Which of the following statements documented by the nurse indicates that the client understood the teaching? a.) "client told to come back to the hospital if would is warm, red, draining" b.) "client advised to call the surgeon if pain increases beyond a level of 4 out of 10" c.) "client verbalized to the nurse the steps to follow if wound becomes red and warm" d.) "client given written instructions regarding wound care and management"

c.) orthostatic hypotension

When assisting a patient from the bed into a wheelchair, the nurse assesses the patient for signs of dizziness upon standing. For what adverse condition is the nurse assessing the patient? a.) deep vein thrombosis b.) circulatory alterations c.) orthostatic hypotension d.) hypertension

a, b, c, d

When preparing a client for a cardiac angiogram what actions should the nurse take? Select all that apply. a.) determine if the client has an allergy to liquid contrast material b.) inform the client that an intravenous infusion will be started before the procedure c.) remind the client to have nothing to eat or drink 8 hours before the procedure d.) instruct the client to remain still during the procedure e.) explain that the client will receive a fast-acting anesthetic

d.) left Sims

When preparing to administer a tap water enema, in which position should the nurse place the client? a.) supine b.) semi-Fowlers c.) right lateral d.) left Sims

a.) clean from the center outward in a circular motion

Which action must a nurse perform when cleaning the area around a Jackson-Pratt wound drain? a.) clean from the center outward in a circular motion b.) remove the drain before cleaning the skin c.) clean briskly around the site with alcohol d.) wear sterile gloves and a mask

d.) maintenance of joint mobility

Which indicates taht performing passive range of motion (ROM) exercises on an unconscious client has been successful? a.) preservation of muscle mass b.) prevention of bone demineralization c.) increase in muscle tone d.) maintenance of joint mobility

b.) Wear support hose or anti embolic stockings

Which instruction would the nurse include in the teaching plan for a postpartal client with a history of thromboembolism to reduce the risk of a recurrence a.) refrain from performing leg exercises b.) Wear support hose or anti embolic stockings c.) flex the muscles at the groin d.) avoid pressure on the thigh muscles

d.) systematic skin assessment at least once per shift

Which is appropriate for the nurse to include in a plan for the prevention of pressure ulcers? a.) daily skin cleaning with soap and hot water b.) gentle massage of bony prominences every shift c.) encouraging the client to sit up as much as possible d.) systematic skin assessment at least once per shift

b.) encourage use of grab bars and railings in the bathroom and halls

Which nursing action best addresses the outcome: The client will be free from falls? a.) use large muscle group when transfer client from bed to chair b.) encourage use of grab bars and railings in the bathroom and halls c.) place emergency contact's telephone number in a prominent place d.) install a monitoring system to help the client in an emergency situation

a.) cleaning the area around the urethral meatus

Which nursing intervention for catheter care should have the highest priority? a.) cleaning the area around the urethral meatus b.) clamping the catheter periodically to maintain muscle tome c.) irrigating the catheter with several milliliters of normal saline solution d.) changing the location where the catheter is taped to the client's leg

d.) early ambulation

Which nursing intervention is most important in preventing postoperative complications? a.) progressive diet planning b.) pain management c.) bowel and elimination d.) early ambulation