1103 Unit 2 Fundamental

A nurse is measuring a client for knee-high antiembolic stockings to help prevent venous stasis. Which of the following actions should the nurse take?

Measure from the client's heel to the popliteal space.

A nurse is measuring a client for knee-high antiembolic stockings to help prevent venous stasis. Which of the following actions should the nurse take?

Measure from the client's heel to the popliteal space. circumference.

8. A nurse observes smoke coming from under the door of the staff's lounge. Which of the following actions is the nurse's priority?

Move clients who are nearby Protect and move clients from close proximity to the fire.

16. A charge nurse is explaining the various stages of the lifespan to a group of newly licensed nurses. Which of the following examples should the nurse include as a developmental task for middle adulthood?

D. The client expresses concerns about the next generation.

A home health nurse is caring for a client who has emphysema and has difficulty with mobility. The client spends mos of his day in a reclining chair. Which of the following physiological responses to prolonged immobility should the nurs expect?

Increased calclum excretion

29. A nurse is measuring the blood pressure of a client who has a fractured femur. The blood pressure reading is 140/94 mm Hg, and the client denies any history of hypertension. Which of the following actions should the nurse take first?

B. Ask the client if they are having pain.

25. A nurse is collecting data from an older adult client as part of a comprehensive physical examination. Which of the following findings should the nurse expect as associated with aging? (Select all that apply.)

B. Decreased height D. Nail thickening E. Decreased bladder capacity

A nurse is planning home care for a school-age child who is awaiting discharge to home following an acute asthma attack. Which of the following growth and development stages according to Erikson should the nurse consider in the planning?

Industry vs. inferiority

5. As part of the admission process, a nurse at a facility is gathering a nutrition history long-term care for a client who has dementia. Which of the following components of the nutrition evaluation is the priority for the nurse to determine from the client's family?

D. Any difficulty swallowing

14. A home health nurse is discussing the dangers of carbon monoxide poisoning with a client. Which of the following information should the nurse include?

D. Carbon monoxide binds with hemoglobin in the body.

The neck is a pivot joint. which the client can rotate by keeping her head midline and turning it from side to side as far as possible.

"Keep your head straight and turn it as far as possible to either side

22. A nurse is providing teaching for an older adult client who has lost 4.5 kg (9.9 lb) since the last admission 6 months ago. Which of the following instructions should the nurse include in the teaching? (Select all that apply.)

"Eat foods that are easy to eat, such as finger foods." D. "Invite family members to eat meals with you." E "Exercise every day to increase appetite."

A nurse is instructing a young adult client about health promotion and illness prevention. Which of the following statements indicates understanding?

"It is important to schedule routine health care visits even if I am feeling well."

A nurse is reinforcing teaching with a client about crutch walking using the swing-through gait. Which of the following statements should the nurse include?

"Move both crutches forward, then lift and move your body past the crutches."

The neck is a pivot joint, which the client can hyperextend by moving her head as far back as possible.

"Move your head from the uptight position back as far as you can,

The neck is a pivot joint on which the dlient can perform lateral flexion by turning her head as if to touch her ear to her shoulder.

"Move your head laterally towards your nght and left shoulder

The neck is a plvot joint, which the client can extend by moving her head forward to rest on her chest, as if nodding her head yes.

"Move your head so that your chin rests on your chest."

This response is an example of the nontherapeutic communication technique of stereotyping which conveys that the client is the same as others and not a unique individual.

"Others who have had this prócedure have had great results.

A nurse is collecting data about a client's range of motion. Which of the following instructions should the nurse give to the client to observe abduction of the shoulder joint?

"Raise your arm from your side forward and upward to beside your head."

A nurse is collecting data about a client's range of motion. Which of the following instructions should the nurse give to the client to observe the elbow rotate for supination?

"Take each of your hands and touch your shoulders."

during client ambulation. Which of the A nurse at an extended-care facility is instructing a class of assistive personnel (AP) about the use of assistive devices following instructions should the nurse include about assisting clients who use a cane?

"When the client moves, he should move the cane forward first."

21. A nurse is counseling an older adult who describes having difficulty dealing with several issues. Which of the following problems verbalized by the client should the nurse identify as the priority?

D. I keep forgetting which medications I have taken during the day."

30. A nurse is performing an admission assessment on a client. The nurse determines the client's radial pulse rate is 68/min and the simultaneous apical pulse rate is 84/min. What is the client's pulse deficit?

31. 16/min The pulse deficit is the difference between the apical and radial pulse rates. It reflects the number of ineffective or nonperfusing heartbeats that do not transmit pulsations to peripheral pulse points. 84-68 = 16

3. A nurse is caring for a client who had a stroke and is scheduled for transfer to a rehabilitation center. Which of the following tasks are the responsibility of the nurse at the transferring facility? (Select all that apply.)

A. Ensure that the client has possession of their valuables. B. Confirm that the rehabilitation center has a room available at the time of transfer. D. Give a verbal transfer report via telephone. E. Complete a transfer form for the receiving facility.

2. A nurse is admitting a client who has acute cholecystitis to a medical-surgical unit. Which of the following actions are essential steps of the admission procedure? (Select all that apply.)

A. Explain the roles of other care delivery staff. B. Begin discharge planning. D. Document the client's wishes E. Introduce the client to their roommate.

12. A nurse educator is presenting a module on basic first aid for newly licensed home health nurses. The client who has heat stroke will have which of the following?

A. Hypotension is a manifestation of heat stroke.

24. A nurse is talking with an older adult client about improving nutritional status. Which of the following interventions should the nurse recommend? (Select all that apply.)

A. Increase protein intake to increase muscle mass. Increase calcium intake to prevent osteoporosis. D. Limit sodium intake to prevent edema. E. Increase fiber intake to prevent constipation.

18. A nurse is collecting history and physical examination data from a middle adult. The nurse should expect to find decreases in which of the following physiologic functions? (Select all that apply.)

A. Metabolism C. Gastric secretions E. Glomerular filtration

26. A nurse is caring for a client in the emergency department who has an oral body temperature of 38.3° C (101° F), pulse rate 114/min, and respiratory rate 22/min. The client is restless with warm skin. Which of the following interventions should the nurse take? (Select all that apply.)

A. Obtain culture specimens before initiating antimicrobials. C. Encourage the client to rest and limit activity. E. Assist the client with oral hygiene frequently.

1. A nurse is performing an admission assessment for an older adult client. After gathering the assessment data and performing the review of systems, which of the following actions is a priority for the nurse?

A. Orient the client to the room

28. A nurse is instructing a group of assistive personnel in measuring a client's respiratory rate. Which of the following guidelines should the nurse include? (Select all that apply.)

A. Place the client in semi-Fowler's position. B. Have the client rest an arm across the abdomen. C. Observe one full respiratory cycle

35. A nurse is performing a neurologic examination for a client. Which of the following assessments should the nurse perform to test the client's balance? (Select all that apply.)

A. Romberg test B. Heel-to-toe walk

36. A nurse is collecting data from an older adult client as part of a neurologic examination. Which of the following findings should the nurse expect as changes associated with aging? (Select all that apply.)

A. Slower light touch sensation B. Some vision and hearing decline C. Slower fine finger movement D. Some short-term decline memory

4. A nurse is preparing the discharge summary for a client who has had knee arthroplasty and is going home. Which of the following information about the client should the nurse include in the discharge summary? (Select all that apply.)

B. Follow-up care C. Instructions for diet and medications E. Contact information for the home health care agency

15. A home health nurse is discussing the dangers of food poisoning with a client. Which of the following information should the nurse include? (Select all that apply.)

B. Immunocompromised individuals are at increased risk for complications for food poisoning C. Clients who are at high risk should eat or drink only pasteurized dairy products E. can Handling prevent raw food and poisoning. fresh food separately

11. A nurse is providing discharge instructions to a client who has a prescription for oxygen use at home. Which of the following information should the nurse include? (Select all that apply.)

B. Nail polish should not be used near a client who is receiving oxygen. C. A "No Smoking" sign should be please on the front of the door E. A fire extinguisher should be readily available in the home

23. A nurse is planning a presentation for a group of older adults about health promotion and disease prevention. Which of the following interventions should the nurse plan to recommend? (Select all that apply.)

B. Pneumococcal immunization examination C Yearly eye D. Periodic mental health screening E Annual fecal occult blood test

A nurse is reviewing safety precautions with a group of young adults at a community health fair. Which of the following recommendations should the nurse include to address common health risks for this age group? (Select all that apply)

B. Wear a helmet while skiing. C. Install a carbon monoxide detector. D. Secure firearms in a safe location.

The nurse should activate the fire alarm system, but it is not the first action the nurse should take.

Activate the fire alarm system.

A nurse is caring for an older adult client who has constipation. Wwhich of the following actions should the nurse take?

Add fluid and fiber to the diet.

20. A nurse is counseling a middle adult client who describes having difficulty dealing with several issues. Which of the following client statements should the nurse identify as the priority to assess further?

B. "It's been so stressful for me to think about having intimate relationships."

A nurse is caring for a client who is immobile. Which of the following actions is the priority for the nurse to contribute to the client's plan of care?

Auscultate breath sounds at least every 2 hr.

17. A nurse is collecting data to evaluate a middle adult's psychosocial development. The nurse should expect middle adults to demonstrate which of the following developmental tasks? (Select all that apply.)

B. spend time focusing on improving your performance C. Welcome opportunities to be creative and productive. E. Become involved with community issues and activities

A nurse is counseling a young adult who describes having difficulty dealing with several issues. Which of the following statements should the nurse identify as the priority to assess further?

C. "I don't even know who I am yet, and now I'm supposed to know what to do."

32. A nurse in a provider's office is preparing to assess a young adult client's musculoskeletal system as part of a comprehensive physical examination. Which of the following findings should the nurse expect? (Select all that apply.)

C. Concave lumbar spine posteriorly E. Muscles slightly larger on the dominant

3. A charge nurse is explaining the various stages of the of newly licensed nurses. Which lifespan to a group of the following examples should the charge nurse include as a developmental task for a young adult?

C. Devoting time to establishing an occupation

A nurse is teaching the guardian of a 12-year-old male client about manifestations of puberty. The nurse should explain that which of the following physical changes occurs first?

C. Enlargement of the testes and scrotum

34. A nurse is caring for a client who reports pain with internal rotation of the right shoulder. This discomfort can affect the client's ability to perform which of the following activities?

C. Fastening or zipping closures on the back while dressing

6. A nurse is caring for a client who fell at a nursing home. The client is oriented to person, place, and time and can follow directions. Which of the following actions should the nurse take to decrease the risk of another fall? (Select all that apply.)

C. Make sure that the client's call light is within reach. D. Provide the client with nonskid footwear. E. Complete a fall-risk assessment.

A nurse is assisting with the care of a client who has developed cardiogenic shock. When evaluating circulation to the client's brain, which of the following pulse sites should the nurse use?

Carotid

nurse is assisting with the adimission of a client to an inpacient unit. Which of the following sources of informati should the nurse use as a primary source of accurate data about the client?

Client concerns

9. A nurse is caring for a client who has history of falls which of the following actions is the nurses priority.

Complete a fall risk assessment This will work as a guide in implementing appropriate safety measures

The nurse should confine the fire by closing doors and windows, but it is not the first action the nurse should take.

Confine the fire by closing doors and windows.

(Select all that apply.) A nurse is monitoring a client for complications of immobility. Which of the following findings should the nurse expect?

Contractures of extremities Crackles in the lungs

A nurse is checking the apical pulse of a client who is taking several cardiovascular medications. Which of the following actions should the nurse take?

Count the apical pulsations for a full minute.

13. A nurse educator is conducting a parenting class for new guardians of infants. Which of the following statements made by a participant indicates understanding?

D. "Once my infant starts to push up, I will remove the mobile from over the crib."

33. A nurse, who is assessing a client's neurologic system, should ask the client to close their eyes and identify which of the following items?

D. A familiar object the nurse the nurse places in the hand.

A nurse is planning care for a client who is immobile and requires continuous mitten restraints. Which of the following interventions should the nurse contribute to client's care plan? (Select all that apply.)

Document restraint checks every 2 hr. Educate the client's family about restraint use. . Implement passive range-of-motion exercises.

is a motion that bends the toes and the foot upward.

Dorsiflexion

Edema can interfere with the accuracy of the pulse aximeter's readings. The nurse should choose an alternative site, such as the earlobe or the nose.

Earlobe

recommendations with a young adult client. A nurse is reviewing CDC immunization Which of the following vaccines should the nurse recommend as routine, rather than catch-up, during young adulthood? (Select all that apply.)

Influenza Pertussis Tetanus

A nurse is assisting with the admission of a client to an inpatient unit, Which of the following sources of information should the nurse use as a primary source of accurate data about the client?

Information the nurse obtains directly from the client is generally the most accurate and provides the best information available. The client is a primary source of information.

is a motion that turns a body part away from the body's midline. Eversion of the foot would be t- laterally.

Everslon

19 . A nurse is preparing a health promotion course for a group of middle adults. Which of the following strategies should the nurse recommend? (Select all that apply.)

Eye examination every 1 to 3 years CDXA screening for osteoporosis Increase intake of carbohydrate in the diet Screening for depressive disorders

Which of the following instruction should a nurse provide to promote the safe use of a cane as an as. who is recovering from a musculoskeletal injury of the left lower extremity?

Hold the cane on the rigmside.

A nurse is reinforcing home safety information with an older adult client. Which of the following statements should the nurse identify as an indication that the client needs further instruction?

I should use my walker carefully when going upstairs."

7. A nurse manager is reviewing with nurses on the unit in the care of a client who has had a seizure. Which of the following statements by a nurse requires further instruction?

I will go to the nurses station for assistance during a seizure stay with a client and use the call light to summon assistance

A nurse is measuring an adult client's tympanic temperature. Which of the following actions should the nurse take?

Insert the probe with a circular motion.

A nurse is working a night shift and caringer several clients at risk for falls. Which of the following actions should the nurse take? (Select all that apply.)

Instruct the clients to use the call light. A Place a fall risk wristband on each of the clients.

A nurse is working a night shift and caring for several clients at risk for falls. Which of the following actions should the nurse take? (Select all that apply.)

Instruct the clients to use the call light. Place a fall risk wristband on each of the clients.

A nurse is caring for several clients at various developmental stages. The nurse understands that according to Erikson, acceptance of death occurs at which of the following stages of psychosocial development?

Integrity vs. Despair

to Erikson. establishing relationships with commitment A nurse is reinforcing teaching with a client about relationship development. The nurse should explain that, according is a primary task of which of the following stages of psychosoclal development?

Intimacy versus isolation During this stage, young adults (18 to 25 years) develop commitments to others and to their careers.

27. A nurse is instructing an assistive personnel (AP) about caring for a client who has a low platelet count. Which of the following instructions is the priority for measuring vital signs for this client?

KA "Do not measure the client's temperature rectally."

A nurse on a medical unit is caring for a clietit who requires seizure precautions. Which of the following interventions should the nurse contribute to the client's plan of care?

Keep the client's bed in the lowest position.

is a localized response that resuits as a local anesthetic effect from cold application.

Numbness

This option is a secondary source of information. Although secondary sources such as family information provide some information for the nurse, they are not as helpful as information the nurse collects directly from the client.

O Family information

A transfer or gait belt helps stabilize the client during the transfer and helps keep him from falling.

O Place a transfer belt on client.

This response is an example of the nontherapeutic communication technique of probing. Asking "why" questions can make the client respond defensively and impede further therapeutic nurse-cient interaction.

O Why are you feeling so anxious

The nurse should perform range-of-motion exercises to prevent muscle atrophy and joint contractures: however, another action is the priority.

Perform range of motion exercises at least two to three times daily.

10. A nurse discovers a small paper fire in a trash can in a client's bathroom. The client has been taken to safety and the alarm has been activated. Which of the following actions should the nurse take?

Place with towels along the base of the door to the clients room

A nurse is assisting a client with range-of-motion exercises of the the client extending her leg and bending her foot floor? the nurse use when documenting feet and ankles. Which of the following terms should and toes downward toward the

Plantar flexion

The nurse should rock the client up to a standing position to create momentum and reduce the strain of pulling or lifting

Pul the client to a standing position.

A nurse is preparing to transfer a client from a bed to a chair. Which of the following actions should the nurse take?

Pull the client to a standing position.

+ A nurse is caring for a client who has pneumonia. The client's oxygen saturation is 85%. Which of the following actions should the nurse take first?

Raise the head of the bed.

A nurse is caring for a client who has pneumonia. The client's oxygen saturation is 85%. Which of the following actions should the nurse take first?

Raise the head of the bed.

Cold application increases the blood's viscosity. Heat application reduces the blood's viscosity.

Reduced blood viscosity

immediate danger. The acronym RACE is a The greatest risk to this client is injury from the fire. Therefore. the first action the nurse should take is to rescue the client from mnemonic for remembering the order of actions to take in the event of a fire. R stands for rescue and remove. A stands for activate the fire alarm system. C stands for contain the fire. E stands for extinguish the fire.

Rescue the client from immediate danger.

Shivering is a systemic response to cold as the body attempts to promote heat production.

Shivering

A skin fold does not have enough capilaries to provide an accurate oxygen saturation reading.

Skin fold

When transferring the client, the nurse should stand with her feet apart to establish balance and a wide base of support.

Stand with the feet together

nurse is caring for a client who is receiving heat applications using an aquathermia pad. Which of the following actions should the nurse take when applying the pad?

Stop the treatment if the client's skin becomes red.

This response is an example of the therapeutic communication technique of providing general leads. It encourages the client to express his feelings and gives the nurse additional data about the client.

Tel me more about your concerns.

A nurse is assisting with admission of a client who is about to have elective surgery. The client tells the nurse she feels anxious. Which of the following responses should the nurse make?

Tell me more about your concerns."

Thickened nails, as well as edema, nail polish, hypothermia, and circulation problems can lead to inaccuracy of the pulse oximeter's readings. The nurse should choose an alternative site for the sensor.

Toe

During this stage, newborns to children 1 year old have others meet their needs and develop trust in care

Trust versus mistrust

facility is reinforcing teaching for with a group of newly A nurse in an extended-care physlologlc changes of aging. Whlch of the following Informatlon should the nurse Include? licensed nurses about the expecte (Select all that apply.)

greater risk for respiratory infections. Decreased cough reflex is correct. Older adults have a decreased cough reflex, Increased airway resistance, fewer alveoli, and a Decreased bladder capacity is correct. Older adults have a decreased bladder capacity and a reduction in renal blood flow. Dehydration of intervertebral discs is correct. Older adults have dehydration of intervertebral discs, decreased muscle strength and ss, and decalcification

A charge nurse in a long-term care facility will be implementing a new protocol to meet the Joint Commission's Nationa Safety Goal of preventing health care-associated pressure ulcers. When informing the staff nurses about the new standard, the nurse should emphasize that which of the following actions is the priority?

idyntify the clients at greatest risk for development of pressure ulcers.

A provider prescribes isometric exercises for a client who has a knee injury. The nurse should instruct the client to expect which of the following results from completing these exercises regularly?

increased muscle strength and tone to reduce muscle wasting