Fundamentals 1
Absent bowel sounds w/distention
A nurse is collecting data for the health history of a client who is postoperative & has paralytic ileus. Which of the following findings should the nurse expect?
Temperature
A nurse is collecting data from a client who reports abdominal pain. Further findings reveal the client has a temperature of 39.2 degrees celsius/102.6 degrees Fahrenheit, a heart rate of 105 beats per minute, a soft non-tender abdomen & menses overdue by 2 days. Which of the following findings should be the nurse's priority?
Carefully remove the gloves & perform proper hand hygiene
A nurse is drawing blood for a lab test from a client that results in a blood spill on her gloved hand. The client has no documented bloodstream infection. Which of the following actions should the nurse take?
"I keep having nightmares about my upcoming surgery."
A nurse is in an oncology clinic is collecting data for a client who is undergoing treatment for ovarian cancer. Which of the following statements by the client indicates she is experiencing psychological distress?
"Sit on the toilet 30 minutes after eating a meal"
A nurse is reinforcing teaching w/older adult client who has constipation. Which of the following statements should the nurse include in the teaching?
Obtaining cotton balls for the tracheostomy care
A charge nurse is observing a newly licensed nurse perform tracheostomy care for a client. Which of the following actions by the newly licensed nurse requires intervention?
Second intercostal space to the right of the sternum
A nurse at a screen clinic is collecting data for a client who reports a history of a heart murmur related to aortic valve stenosis. At which of the following anatomical areas should the nurse place the stethoscope to auscultate the aortic valve?
Screening groups of older adults in nursing care facilities for early influenza manifestations
A nurse is assisting w/planning a community campaign about seasonal influenza. Which of the following plans should be included as a secondary prevention strategy?
Pericardial Friction Rub
A nurse is auscultating the heart sounds of a client who has developed chest pain & worsens w/inspiration. The nurse hears a high-pitched scratching sound w/diaphragm of the stethoscope placed at the 3rd intercostal space of the left sternal border. What is the heart sound?
Administer analgesics to the child on a routine schedule throughout the day & night
A nurse is caring for a child who is postoperative following a tonsillectomy. Which of the following actions should the nurse take?
Encourage the client to express his thoughts about death & dying
A nurse is caring for a client who has a terminal illness. The client asks several questions about the nurse's religious beliefs related to death & dying. Which of the following actions should the nurse take?
"Tell me what I can do to help you overcome your fear of giving yourself injections."
A nurse is caring for a client who has type 1 diabetes mellitus & is resistant to learning self-injection of insulin. Which of the following statements should the nurse make?
Sit & Hold the client's hand
A nurse is caring for a client who is in the terminal stage of cancer. Which of the following actions should the nurse take when she observes the client crying?
Disconnect the machine & measure B.P. manually every 15 minutes
A nurse is caring for a client who is unstable & has vitals taken every 15 minutes. The nurse notices the machine begins to measure the B.P. at varied intervals & the readings are inconsistent. What should the nurse do?
Identify the client using 2 identifiers
A nurse is caring for a client who requires a chest x-ray. Prior to the client being transported for the procedure, which of the following actions should the nurse take first?
Remove the restraints one at a time
A nurse is caring for al older client who is violent and attempting to disconnect her IV lines. The provider prescribes soft wrist restraints. Which of the following actions should the nurse take while the client is in restraints?
"What worries you about being without your teeth?"
A nurse is caring for an older client who becomes agitated when the nurse requests that the client's dentures be removed prior to surgery. What should be the nurses response?
Evaluate pedal pulses
A nurse is collecting data for a client who has decreased circulation in his left leg. Which of the following actions should the nurse take first?
Grasp a skin fold on the chest under the clavicle, release it & note whether it springs back
A nurse is collecting data for a client who has had diarrhea & decreased urination for several days. Which of the following actions should the nurse take to determine if the client is dehydrated?
"There are times I should use soap & water rather than an alcohol-based hand rub to clean my hands"
A nurse is instructing an A.P. about proper hand hygiene. Which of the following statements by the A.P. indicates an understanding of the teaching?
Count apical pulse for 1 minute & describe the rhythm in the chart
A nurse is measuring vitals for a client and notices an irregularity in the pulse. Which of the following actions should the nurse take?
Place the bladder of the cuff over the posterior aspect of the thigh
A nurse is obtaining blood pressure in a client's lower extremity. Which of the following actions should the nurse take?
Temporal
A nurse is planning to obtain vitals of a 2-year-old child who is experiencing diarrhea & who may have a right ear infection. Which of the following routes should the nurse use to obtain the temperature?
Attempt to increase the client's self-motivation
A nurse is planning weight loss strategies for a group of clients who are obese. Which of the following actions by the nurse will improve the clients' commitment to a long-term goal of weight loss?
Notify the provider about the client's decision
A nurse is preparing for a client who is scheduled for a hysterectomy for transport to the O.R. when the client states she no longer wants have the surgery. Which of the following actions should the nurse take?
Raise the level of the bed
A nurse is preparing to perform oral care for a client who is unresponsive. Which of the following actions should the nurse plan to take?
Lock the wheels on the bed & stretcher
A nurse is receiving a client from the PACU who is postoperative following abdominal surgery. Which of the following actions should the nurse take to transfer the client from the stretcher to the bed?
The client reports severe pain
A nurse is reinforcing teaching of postoperative deep breathing & coughing exercises w/client who will have emergency surgery for appendicitis. Which of the following statements indicates a lack of readiness to learn by the client?
"Donate autologous blood before the surgery"
A nurse is reinforcing teaching with a client who is scheduled for arthroplasty in the next month and might require a blood transfusion. The client expresses concern about the risk of acquiring an infection from the blood transfusion. What should the nurse suggest?
"I should expect my heart rate to take longer to return to normal after exercise as I get older."
A nurse is reinforcing teaching with a group of older adults about expected changes of aging. Which of the following statements by a group member indicates that the teaching has been effective?
The signature on the preoperative consent form is the client's
A nurse is witnessing a client signing an informed consent form for surgery. Which of the following describes what the nurse is affirming by this action?
"Using a cuff that is too small will result in an accurately high reading"
A nurse observes an A.P. to obtain blood pressure w/regular-sized cuff for a client who is obese. Which of the following explanations should the nurse give the A.P?
Data collection for the client
A nurse on a medical surgical unit is admitting a client. Which of the following information should the nurse document in the client's record first?
Obtain client information
A nurse on a medical-surgical unit is caring for a client. Which of the following actions should the nurse take first when using the nursing process?
The nurse washes with her hands held higher than her elbows
A nurse on a medical-surgical unit is washing her hands prior to assisting w/surgical procedure. Which of the following actions by the nurse demonstrates proper surgical hand-washing technique?
Place the wheelchair at a 45-degree-angle to the bed
A nurse on a rehab unit is preparing to transfer a client who is unstable to walk from a bed to a wheelchair. Which of the following techniques should the nurse use?
The involvement of the client in planning the change
A nurse is reinforcing teaching w/client who has heart failure about how to reduce his daily intake of sodium. Which of the following factors is the most important in determining the client's ability to learn new dietary habits?