Finals: FUNDA 2
A nurse is performing suctioning for a client who has a tracheostomy. Which of the following actions should the nurse take?
Pull suction catheter back 1 cm (0.5 in) if the client starts coughing
A nurse is helping a client change his hospital gown. The client has an IV infusion in an infusion pump. Which of the following actions should the nurse take first?
Remove the sleeve of the gown from the arm without the IV line
A nurse is caring for a group of clients who are receiving oxygen therapy. Which of the following clients should the nurse plan to see first?
A client who has heart failure and is receiving 100% oxygen via a partial rebreather mask
A nurse is changing the bed linens for a client who is on bed rest. Which of the following actions should the nurse plan to take?
Hold the linens away from the body and clothing.
A nurse is caring for a client who has major fecal incontinence and reports irrigation in the perianal area. Which of the following actions should the nurse take first?
Check the clients perineum
A nurse is collecting a urine specimen for culture and sensitivity for a client who has automate tract infection. The client has an in dwelling urinary catheter in place. Which of the following actions should the nurse take?
Clamp the tubing below the collection port
A nurse is collecting data from a client who has an o send of severe back pain of i know origin. Which of the following questions should the nurse ask to encourage discussion with the client?
"What do you think caused the onset of your pain?"
A nurse is caring for a client who has a prescription for collection of a sputum specimen for culture and sensitivity. Which of the following actions should the nurse plan to take when obtaining the specimen?
Collect the specimen upon arising in the morning
A nurse is assisting a client who is eating at mealtime. The client grabs her neck with both hands and appears frightened. Which of the following actions should the nurse take first?
Determine whether the client is able to breathe
A nurse is preparing to administer eye drops to a client following surgery. Which of the following actions should the nurse take when instilling the eye drops?
Drop the eye medication in the outer third of the lower conjunctival sac.
A nurse is caring for a client who has a NG tube for intermittent enteral feedings. Which of the following actions should the nurse take?
Elevate the clients head 45* before the feeding
A nurse is performing eye irrigation for a client who was exposed to smoke and ash. Which of the following actions should the nurse take?
Exert pressure on the bony prominences when holding the eyelids open
A nurse is administering a cleansing enemy to a client who is scheduled for a diagnostic procedure. Which of the following actions should the nurse take?
Insert the tip of the tubing 8 cm (3.1in)
A nurse is preparing to anchor with tape the catheter tube for male client who has a newly inserted indwelling urinary catheter. At which of the following locations should the nurse take the catheter?
Lower abdomen
A nurse is changing the dressings for a client who has two Penrose drains near an abdominal incision. Which of the following adhering decides is the best choice for the nurse to use to decrease skin irrigation?
Montgomery straps
A nurse is planning to collect a stool specimen for ova and parasites from a client who has diarrhea. Which of the following actions should the nurse take when collecting the specimen?
Place the stool specimen collection container in a biohazard bag.
A nurse is caring for a client who has a history of dysthymias. Upon entering the room, the nurse discovers the client is unresponsive to verbal or painful stimuli, has no respirations, and is pulse less. Which of the following actions should the nurse take first?
Start chest compressions
A nurse is preparing to assist with ambulation of an older adult who was on bed rest for 3 days. Which of the following actions should the nurse take to decrease the risk of a fall?
Use a gait belt during ambulation
A nurse is contributing to the plan of care for a client who has fluid volume excess. Which of the following interventions should the nurse plan to include to monitor the clients weight?
Weigh the client on arising
A nurse is performing a straight urinary catheterization for a female client who has urinary retention. Which of the following actions indicates the nurse is maintaining sterile technique?
Wipes the labia minora in an anteroposterior direction
