Foundations Final Practice

A nurse is caring for a client who has returned to the unit following a surgical procedure. 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 reviewing a client's prescription for 1,000 mL of 5% dextrose in water IV to infuse over 8 hr. At 1400, thenurse observes that there is 500 mL of solution remaining in the client's current IV bag. At what time should thenurse administer the next bag of IV solution?

1800

A nurse is preparing to infuse a 250-mL unit of packed RBCs over 2 hr. The drop factor of the manual IV tubing is15 gtts/mL. The nurse should adjust the flow rate to deliver how many drops per minute? (Round the answer to thenearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

31

A nurse is caring for pt who has an NG tube. nurse tests the pH of secretion to determine if tube is correctly placed. which reading would nurse expect?

4.0

A nurse is preparing to administer total parental nutrition (TPN) 1800 mL to infuse over 24 hr. The nurse should setthe IV pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if itapplies. Do not use a trailing zero.

75

a nurse is preparing to administer penicillin IM to an adult client. which of the following angles should the nurse use for injection in the clients ventrogluteal muscle

90

a nurse on the med surg unit is conducting a fall risk for four clients. the nurse should identify that which of the following client is the greatest risk for a fall

An older adult client who is confused and has urinary frequency

A nurse is assessing a client's radial pulse and determines that the pulse is irregular. Which of the following actions should the nurse take?

Assess the apical pulse for a full minute

A client receives the wrong medication. the nurse who made the medication error should take which of the following actions first?

Assess the client

The nurse auscultates bilateral breath sounds on a client two days after surgery and notices absent breath sounds in the bases. The nurse recognizes this is most likely due to which of the following?

Atelectesis

A nurse is caring for a client who has chronic obstructive pulmonary disease (COPD). The client tells the nurse, "I can feel the congestion in my lungs, and I certainly cough a lot, but I can't seem to bring anything up." Which of the following actions should the nurse take to help this client with tenacious bronchial secretions?

Encouraging the client to drink 2 to 3 L of water daily

A nurse is providing preoperative teaching by demonstrating diaphragmatic breathing to a client who is scheduled for surgery in the morning. Which of the following actions should the nurse include in the demonstration?

Inhale slowly and evenly through her nose.

A nurse is caring for a client who is prescribed bedrest. The plan of care indicates that the client should perform isometric exercises every 2 hours. Which of the following actions should the nurse take as directed by the plan of care?

Instruct the client to tighten muscle groups for a short period, and then relax.

A nurse is assessing a client who has postoperative atelectasis and is hypoxic. Which of the followingmanifestations should the nurse expect?

Intercostal retractions

A nurse is caring for an older adult client who was alert and oriented at admission, but now seems increasingly restless and intermittently confused. Which of the following actions should the nurse take to address the client's safety needs?

Move the client to a room closer to the nurses' station.

A nurse is assessing a client who has a sodium level of 116 mEq/L. Which of the following findings should the nurse interpret

Nausea and vomiting

A nurse is preparing an in-service presentation for a group of newly licensed nurses about the use of restraints. Which of the following should the nurse include as criterion for apply restraints.

The nurse has already considered alternatives to restraints. Restraints physically prevent a client from moving freely in the environment. However, they are a last resort. The nurse must consider other alternatives before implementing a restraint device.

A nurse is preparing to insert an indwelling urinary catheter for a female client. which of the following instructions should the nurse give the clients as the catheter is inserted

bear down

A nurse is caring for a client who has an indwelling urinary catheter and notes blood tinged urine in the catheter bag. The nurse recognizes this finding can be a manifestation of which of the following urinary alterations?

bladder infection

a nurse is assessing for cyanosis in a client who has dark skin. which of the following items should the nurse examine to identify cyanosis

conjunctivae

A nurse is caring for a client who is postoperative following abdominal surgery. The surgeon initially prescribes a clear liquid diet. Which of the following items should the nurse include on the client's lunch tray?

cranberry juice

A client is receiving oxygen therapy via nasal canal. The nurse should explain that this method of oxygen delivery does which of the following?

delivers a low concentration of oxygen

A nurse is caring for a client who has pneumonia. which of the following actions should the nurse take to promote thinning of respiratory secretions

encourage the client to increase fluid intake

A nurse is prioritizing care for two clients at the start of the shift. The first client, who is 1 day postoperativefollowing a partial bowel resection, requires a dressing change, total parental nutrition administration and reports apain level of 6 on a scale from 0 to 10. The second client, who has a newly inserted percutaneous gastrostomytube, requires a tube feeding, dressing change, and daily weight. Which of the following nursing actions should thenurse plan to complete first?

obtain vital signs for both clients

a nurse is preparing a sterile field. which of the following actions should the nurse identify as contaminating the field

opening a sterile package over the middle of the sterile field

When assessing a patient with hypoxia, which of the following findings should the nurse expect?

tachycardia

a nurse is removing an indwelling urinary catheter that an older adults has had in place for 2 days. the nurse should assess the client for which of the following expected outcomes after catheter removal

temporary urinary retention

a nurse is reviewing the arterial blood gas values for a client. The pH is 7.32, paco2 is 48, and hco3 is 23

respiratory acidosis

a nurse asks a client how he is feeling. the client states "im feeling a bit nervous today". which of the following responses should the nurse make?

"Please explain what you mean by the word 'nervous.'"

A nurse is preparing to administer clindamycin 300 mg by intermittent IV bolus over 30 min to a client who has staphylococciinfection. Available is clindamycin premixed in 50 mL 0.90% sodium chloride (NaCl). The nurse should set the IV pump to deliver how many mL/hr? (Round the answer to the nearest whole number).

100 STEP 1: What is the unit of measurement the nurse should calculate? mL/hr STEP 2: What is the volume the nurse should infuse? 50 mL STEP 3: What is the total infusion time? 30 min STEP 4: Should the nurse convert the units of measurement? Yes (min does not equal hr) 60 min/30 min = 1 hr/X hr X = 0.5 hr STEP 5: Set up an equation and solve for X. Volume (mL)/Time (hr) = X mL/hr 50 mL/0.5 hr = X mL/hr X = 100

A nurse should teach which of the following clients requiring crutches about how to use a three-point gait?

A client who has a right femur fracture with no weight bearing on the affected leg

A nurse is caring for a female client in the ED who reports shortness of breath and pain in the lung area. She states that she started taking birth control pills 3 weeks ago and that she smokes. Her heart rate is 110/min, respiratory rate 40/min, and blood pressure 140/80 mm Hg. Her arterial blood gases are pH 7.50, PaCO2 29 mm Hg, PaO2 60 mm Hg, HCO3 20 mEq/L, and SaO2 86%. Which of the following is the priority nursing intervention?

Administer oxygen via face mask

a nurse is caring for a client who is immobile. which of the following actions is the priority for the nurse to include in the clients plan of care

Auscultate breath sounds at least every 2 hr. The priority action the nurse should contribute to the plan of care when using the airway, breathing, circulation approach to client care is auscultating breath sounds to determine the client's need for suctioning. With inactivity, secretions can pool in the airways, diminishing breath sounds and causing crackles and dyspnea.

a nurse is assessing a clients cranial nerves as a part of neurological examination. which of the following actions should the nurse take to assess cranial nerve iii

Checking the pupillary response to light

A nurse is reviewing the medical record of a client who has a potassium level of 3.0 meq/L. Which of the following findings should the nurse recognize as a potential causative factor?

Client has an NG tube to gastric suction

A nurse is assessing a client who has chronic respiratory insufficiency. Which of the following findings should the nurse expect as result of the long-term inadequate oxygen ?

Clubbing of the fingers

A nurse is performing tracheostomy care for a client and suctioning to remove copious secretions. Which of the following actions should the nurse take?

Suction two to three times with a 60-second pause between passes

A nurse is providing oral care for a client who is immobile. Which of the follow actions should the nurse take?

Turn the client on his side before starting oral care

A nurse is caring for a client who is postoperative. The nurse should base her pain management interventions primarily on which of the following methods of determining the intensity of the client's pain?

The client's self-report of pain severity

A nurse accidentally sticks her hand with a syringe needle after administering an IM injection to a client. Which of the following actions should the nurse take first?

Wash the area of the puncture thoroughly with soap and water

A nurse is caring for a client who has methicillin-resistant Staphylococcus aureus (MRSA) in an abdominal wound. The nurse enters the room to check the client's pulse. Which of the following actions should the nurse take?

Wear clean gloves

A nurse is implementing a bowel training program for a client . For the program to be effective the client should be taken to the bathroom at which of the following times?.

When the client has the urge to defecate

A nurse is assessing a client who shows signs of hypoxemia during an asthma attack. Which of the following manifestations should the nurse expect?

agitation

A nurse is assessing a client who has asthma. Which of the following areas should the nurse evaluate as the most reliable indicator of central cyanosis?

oral mucosa

When reviewing a patients lab report of blood gas findings, HCO3- 18mEq/L and PaCO2 28mm Hg. Which of the following pH values and conditions should the nurse expect when interpreting these findings

decreased pH and metabolic acidosis

A nurse in the emergency department is caring for a client who collapsed after playing football on a hot day. After reviewing the admission laboratory findings, the nurse recognizes that these findings are consistent with which of the following conditions?

dehydration

A nurse is removing PPE after giving direct care to a client who requires isolation. Which of the following PPE items should the nurse remove first?

gloves

A nurse is providing discharge teaching for a client who requires home oxygen therapy. which of the following should the nurse identify as an indication that the client needs further teaching

i will wear synthetic clothing and woolen socks with my oxygen

A nurse is performing pulmonary hygiene for a patient who has pneumonia and positions the patient on his left side in Trendelenburg position. From which of the following lung segments should the nurse expect secretions to be mobilized with the client in this position?`

lateral segment of the right lower lobe

A nurse is assisting with transferring a client from the bed to a wheel chair. Which of the following actions should the nurse take?

lock the wheels of the bed and the wheelchair

nurse is preparing pt for outpatient surgery. after nurse inserts IV cat, the client reports pain in the insertion area. which action should nurse take

remove the catheter and insert another into a different site

A nurse is auscultating a patient's lung sounds and identifies crackles in the left lower lobe. Which of the following interventions should the nurse take?

repeat auscultation after asking to breath deeply and cough

a nurse is caring a client whose arterial blood gas results show a pH of 7.3 and pco2 of 50

respiratory acidosis

A nurse is preparing to administer an intramuscular injection of meperidine to a clinet. Which of the following is the priority assessment the nurse should complete

respiratory rate

a nurse is assessing a client and discovers the infusion pump with the clients TPN solution is not infusing. The nurse should monitor the client for which of the following conditions

shakiness and diaphoresis

A nurse is caring for a client who receives intermittent enteral feedings through an NG tube. Before administering a feeding, the nurse should measure the gastric residual for which of the following purposes?

to identify delayed gastric emptying

A nurse is caring for a client who has impaired renal function. For which of the following findings should the nurse notify the provider?

urine output of 175 mL in the past 8 hr **At least 30 mL/ hr

A nurse is using the communication principle of presence when establishing a collaborative relationship with a client. Which of the following actions should the nurse take?

use attentive listening with the client.

A nurse is providing discharge teaching about clean intermittent self-catheterization for a client who has BPH - benign prostatic hyperplasia. Which of the following instructions should the nurse include

use soap and water to wash the catheter after each use

A nurse is reviewing the laboratory results of a client who has a pressure ulcer. The nurse should identify an elevation in which of the following laboratory values as an indication that the client has developed an infection

wbc count