Fundamentals 1; learning RN 3.0

A nurse is planning to obtain the vital signs of a 2- year old who is experiencing diarrhea and who might have a right ear infection. Which of the following routes should the nurse use to obtain a temperature?

The nurse should use the temporal route' noninvasive and can be used to obtain a temp in a toddler who might have an ear infection and who is having diarrhea [other choices are rectal, tympanic, and oral]

A nurse in an oncology clinic is assessing a client who is undergoing treatment for ovarian cancer. Which of the following statements by the client indicates she is experiencing psychological distress?

correct: "I keep having nightmares about my upcoming surgery." Nightmares and sleep disturbances are manifestations of anxiety and post-traumatic stress disorder. These indicate that the client is at risk for experiencing psychological distress. incorrect: "My parents are retired, and they have come to help out with our children." Clients who have social and emotional support systems tend to experience less psychological distress. "I am going to ask my husband to go to counseling with me." Open communication is an important method to improve relationships that might be strained. Seeking counseling is a positive strategy. "My girlfriends bought me a nice wig." Clients who have social and emotional support systems tend to experience less psychological distress.

A nurse on a medical-surgical unit is admitting a client. Which of the following info should the nurse document in the client's record first?

Assessment, then plan of care, then interventions performed, then evaluation of progress.

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 client's commitment to a long-term goal of weight loss?

Attempt to increase the client's self-motivation: Motivation to learn is important in improving a client's commitment to achievement of a health goal, as well as increasing the amount and speed of learning.

A charge nurse is teaching adult CPR to a group of newly licensed nurses. Which of the following actions should the charge nurse teach as the first response in CPR?

Confirm unresponsiveness, then call for assistance, begin chest compressions, and give rescue breaths.

A nurse is measuring vital signs for a client and notices an irregularity in the pulse. Which of the following actions should the nurse take?

Count the apical pulse rate for 1 full minute and describe the rhythm in the chart. If the peripheral pulse is irregular, the nurse should auscultate the apical pulse for 60 seconds to obtain an accurate rate. The nurse should document the irregularity in the client's medical record. The nurse should assess pedal pulses to determine circulation in the client's lower extremities. The nurse should use a Doppler ultrasound for a pulse that is non palpable or very difficult to palpate. The nurse should assess all peripheral pulses to determine the equality of blood perfusion to the extremities.

A nurse is caring for a client who is unstable and has vital signs measured every 15 minutes by an electronic blood pressure machine. The nurse notices the machine beings to measure the blood pressure at varied intervals and the readings are inconsistent. Which of the following actions should the nurse take?

Disconnect the machine and measure the blood pressure manually every 15 min- if the nurse questions the reliability of monitoring equipment, a manual process should be used. Also, malfunctioning equipment can pose a safety risk for the client so it must be tagged and removed.

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 and dying. Which of the following actions should the nurse take?

Encourage the client to express his thoughts about death and dying- this is the therapeutic technique of reflecting. Do not ask close-ended questions, put the client's issue on hold, or change the subject in response.

A nurse on a med-surg unit is caring for a client. Which of the following actions should the nurse take first when using the nursing process?

Obtain client information, document nursing care needs, then identify goals, then evaluate the effectiveness of care.

A nurse on a rehabilitation unit is preparing to transfer a client who is unable to walk from a bed to a wheelchair. Which of the following techniques should the nurse use?

Place the wheelchair at a 45 degree angle to the bed. Positioning a wheelchair at a 45 degree angle allows the client to pivot, lessening the amount of rotation required. The nurse should assume a wide stance, and instruct the client to lean forward from the hips. The nurse should stand on the client's side that requires the most support.

A nurse is to perform mouth care for a unresponsive client. Which of the following actions should the nurse plan to take?

Raise the level of the bed. Client should be side-lying, not supine, and the side rail closest to the nurse should be lowered. The nurse should never insert her fingers into the mouth of the unresponsive client.

A community health nurse is preparing a campaign about seasonal influenza. Which of the following plans should the nurse include as a secondary prevention?

Screening groups of older adults in nursing care facilities for early influenza manifestations- Screening older adults who have manifestations of illness to determine if they have influenza is an example of secondary prevention. Secondary prevention is focused on preventing complications of an illness or providing care to prevent illness from becoming severe. Administering influenza immunizations is an example of primary prevention for people who are healthy but in danger of becoming ill. Educating clients about the dangers of influenza is an example of primary prevention for people who are healthy but in danger of becoming ill. Finding rehabilitation programs for older adults who have complications from influenza is an example of tertiary prevention, which tries to prevent complications and help people recover from an existing illness.

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?

Sit and hold the client's hand- with this action, the nurse uses the therapeutic communication techniques of silence, tough, and offering of self to the client. Do not shift responsibility of helping the client to others, put the client's needs on hold, or fail to acknowledge the client's distress.

A nurse is providing teaching to a 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?

The involvement of the client in planning the change- according to EBP, client involvement in planning dietary changes is the most important factor in the client's ability to learn new habits.

A nurse is obtaining the blood pressure in a client's lower extremity. Which of the following actions should the nurse take?

The nurse should place the bladder of the cuff over the posterior aspect of the thigh- this is the correct position for the nurse to place the bladder of the cuff when measuring a lower extremity blood pressure. The nurse should position the cuff 2.5cm above the popliteal artery, measure the blood pressure with the client prone if possible [or supine with the knee flexed] and the nurse should auscultate the blood pressure at the popliteal artery.

A nurse is caring for an older adult 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?

The nurse should remove the restraints one at a time for a client who is violent or noncompliant. Restraint prescriptions can only be written for a 24 hr period and cannot be a PRN prescription. The nurse should ensure the restraints are removed and ROM exercises are performed every 2 hours, and the nurse should not tie the restraints to the side rails because this can injure the client if the rails are lowered.

A nurse is witnessing a client sign an informed consent form for surgery. Which of the following describes what the nurse is affirming by this action?

The signature on the preoperative consent form is the client's. It is the provider's job to inform the client about the procedure [explain it] and explain the risks and benefits. The nurse does not need to witness the provider's explanation of the procedure.

A nurse is preparing to perform mouth care for a unresponsive client. Which of the following actions should the nurse plan to take?

Correct: Raise the level of the bed. The nurse should raise the bed to allow for the use of proper body mechanics and reduce the risk of self-injury. incorrect: Inspect the client's mouth using a finger sweep. To prevent the risk of care-giver injury, the nurse should never insert fingers into the mouth of an unresponsive client. Place the client supine. To prevent the risk of aspiration, the nurse should raise the client's head to 30° or turn the client to a side-lying position. Keep both side rails up. To prevent straining and the risk of self-injury, the nurse should lower the near side rail before performing mouth care.

A nurse is demonstrating postoperative deep breathing and coughing exercises to a client who will have emergency surgery for appendicitis. Which of the following statements indicates a lack of readiness to learn by the client?

Correct: The client reports severe pain. A client who is experiencing severe pain is not able to concentrate and therefore, is not ready to learn a new activity. Incorrect: The client asks the nurse to repeat the instructions before attempting the exercises. Asking the nurse to repeat the instructions demonstrates that, while the client might not totally understand the mechanics of performing the exercises, he does have a readiness to learn the activity. The client asks the nurse how often deep breathing should be done after surgery. Asking about the frequency of the activity indicates a readiness to learn. The client is motivated to perform the activity and wants to know how often to do it. The client tells the nurse that this exercise will probably be painful after surgery. The client's statement indicates to the nurse that the client has a readiness to learn because he is able to think about the possible effects of the exercise following surgery.

A nurse is caring for a child who is postoperative following a tonsillectomy. Which of the following actions should the nurse take?

Correct: Administer analgesics to the child on a routine schedule throughout the day and night. To soothe the client's throat following a tonsillectomy, the nurse should administer pain medication routinely around the clock. The nurse can provide the medication rectally or intravenously to avoid the oral route. Incorrect: Encourage the child to cough frequently to clear congestion from anesthesia. The child should be discouraged from coughing or clearing the throat following a tonsillectomy because these actions can contribute to bleeding. Place a heating pad at the child's neck for comfort. The nurse should offer an ice collar, not a heating pad, to ease the child's pain. Provide the child with ice cream when oral intake is initiated. Milk products, such as ice cream and pudding, are usually avoided because they coat the mouth and throat, causing the child to clear the throat. Clearing the throat can lead to bleeding. Ice chips and ice pops are usually the first items offered following a tonsillectomy.

A nurse is admitting a client who has decreased circulation in his left leg. Which of the following actions should the nurse take first?

Correct: Evaluate pedal pulses. For a client who has decreased circulation in the leg, evaluating pedal pulses is critical in order to determine adequate blood supply to the foot. The nurse should apply the safety and risk reduction priority-setting framework. This framework assigns priority to the factor posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's Hierarchy of Needs, the ABC priority-setting framework, or nursing knowledge to identify which risk poses the greatest threat to the client. Incorrect: Obtain a medical history. The nurse should obtain the client's medical history. However, there is another action the nurse should take first. Measure vital signs. The nurse should obtain baseline vital signs. However, there is another action the nurse should take first. Assess for leg pain. The nurse should assess the client for pain. However, there is another action the nurse should take first.

A nurse is preparing to provide tracheostomy care for a client. Which of the following actions should the nurse take first?

"Perform hand hygiene"- According to EBP, the nurse should first perform hand hygiene before touching the client or performing any skills, such as tracheostomy care. This is vital because contamination of the nurses's hands is a primary source of infection. The nurse should also, after performing hand hygiene, don sterile gloves, stabilize the tracheostomy tube, and open all supplies and solutions.

A nurse is performing an abdominal assessment for an adult client. Identify the correct sequence of steps for this assessment.

Inspect, auscultate, percuss, then palpate.

A nurse is caring for a client who requires a chest x-ray. Prior o the client being transported for the procedure, which of the following actions should the nurse take first?

Identify the client using two identifiers: Other choices: explain the x-ray procedure to the client, help the client into a wheelchair before the transporter arrives, and ask if the client has any questions.

A nurse in the ER is assessing a client who reports diarrhea and decreased urination for 4 day.s Which of the following actions should the nurse take to assess the client's skin turgor?

Grasp the skin fold on the chest under the clavicle, release it, and note whether it springs back. The nurse should used this technique for assessing skin turgor. If the client has good turgor and is properly hydrated, the skin will immediately return to normal; with dehydration, the skin will remain tented. The nurse can also assess turgor by grasping a skin fold on the back of the forearm. Pushing on the fingernail bed until it blanches and seeing how long it takes to return to pink in color assesses capillary refill. Pressing the skin in above the ankle for 5 seconds, releasing it, and noting the depth of the impression determines the extent of pitting edema. Measuring the skin fold thickness at the upper arm using a pair of calibrated skinfold calipers assesses the client's body fat percentage.

A nurse observes an AP preparing to obtain BP with a regular size cuff for a client who is obese. Which of the following explanations should the nurse give the AP?

correct: "Using a cuff that is too small will result in an inaccurately high reading." Blood pressure cuffs come in various sizes, and the correct size cuff is necessary to obtain a reliable measurement. Blood pressure readings can be falsely high if the cuff is too small for the client. Incorrect: "The reading will be inaudible if the cuff is too small for the client." Although the blood pressure reading for a client who is obese may be difficult to hear with any cuff, a cuff that is too small for the client will not yield an inaudible reading. "The width of the cuff bladder should be 75% of the circumference of the client's arm." The width of the cuff bladder should be 40% of the circumference of the client's arm. "As long as the cuff will circle the arm the reading will be accurate." A cuff that is an incorrect size for the client will not yield an accurate reading.

A nurse is providing teaching to an older adult client who has constipation. Which of the following statements should the nurse include in the teaching?

"Sit on the toilet 30 minutes after eating a meal."- Increased peristalsis occurs after food enters the stomach. Siting on the toilet 30 min after eating a meal, regardless of feeling the urge to defecate, is a recommended method of bowel retraining to treat constipation. The nurse should instruct the client to consume a minimum of 1,500mL of fluid to prevent constipation. The nurse should instruct the client to increase consumption of coarse-fiber and whole grains, rather than refined-fiber foods. The nurse should not recommend intake of daily laxatives because consistent use hinders natural defecation habits and can cause constipation, rather than cure it.

A nurse on a medical-surgical unit is washing her hands prior to assisting with a surgical procedure. Which of the following by the nurse demonstrates proper surgical hand-washing technique?

The nurse washes her hands held higher than her elbows [so water and soapsuds can drain away from the clean area toward the dirty area]. 15 strokes each, using fiction and a brush, and washing the hands then elbows first.

A nurse at a screening clinic is assessing 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?

Second intercostal space to the right of the sternum- the aortic valve is located in the second intercostal space to the right of the sternum. Aortic stenosis produces a mid-systolic ejection murmur that can be heard clearly at the aortic area with the client leaning forward. The mitral valve is located in the fifth intercostal space just medial to the mid-clavicular line. The pulmonic valve is located in the second intercostal space to the left of the sternum. The tricuspid valve is located in the fifth intercostal space to the left of the sternum.

A nurse is teaching a group of older adults about expected changes of aging. Which of the following statements by a group member indicates the teaching has been effective?

"I should expect my heart rate to take longer to return to normal after exercise as I get older." Older adults experience decreased cardiac output, which causes increased pulse rate during exercise. The pulse rate also takes longer to return to normal after exercise. Incorrect "Urinary incontinence is something I will have to live with as I grow older." Although bladder capacity decreases in older adults, urinary incontinence is not an expected finding and older adults should report incontinence so that it can be investigated and treated. "I can expect to have less ear wax as I get older." Older adults have an increased buildup of cerumen in the ears, which may increase expected incidence problems with hearing loss. "My stomach will empty more quickly after meals as I grow older." Decreased gastric emptying is an expected finding in older adults.

A nurse is caring for a client who has Type 1 diabetes mellitus and is resistant to learning self-injection of insulin. Which of the following statements should the nurse make?

"Tell me what I can do to help you overcome your fear of giving yourself injections."- This response illustrates the therapeutic communication technique of clarifying and offering of self. It is important for the nurse to allow the client to express feelings and fears and to support the client in learning how to give the injections.

A nurse is caring for an older adult client who becomes agitated when the nurse requests that the client's dentures be removed prior to surgery. Which of the following responses should the nurse make?

"What worries you about being without your teeth?" This response by the nurse is therapeutic because it validates the client's feelings of agitation and seeks a reason for it. Do not focus on inappropriate issues or individuals, ignore or dismiss the client's feelings, or disagree with the client by offering unsolicited advice.

A nurse is caring for a patient who is postop and has a paralytic ileum. Which of the following abdominal assessments should the nurse expect?

correct: Absent bowel sounds with distention Paralytic ileus is an immobile bowel. With this disorder, bowel sounds are absent and the abdomen is distended. incorrect: Hyperactive bowel sounds with diarrhea Paralytic ileus is an immobile bowel. With this disorder, bowel sounds are absent, the abdomen is distended, and there is no flatus or stool. Normal bowel sounds with increased peristalsis Paralytic ileus is an immobile bowel with decreased peristalsis. With this disorder, bowel sounds are absent, the abdomen is distended, and there is no flatus or stool. Frequent bowel sounds with flatus Paralytic ileus is an immobile bowel. With this disorder, bowel sounds are absent, the abdomen is distended, and there is no flatus or stool.

A nurse is providing preoperative teaching to a client who is scheduled for arthroplasty in the next month that might require a blood transfusion. The client expresses concern about the risk of aquiring an infection from the blood transfusion. Which of the following statements should the nurse make to the client?

Correct: "Donate autologous blood before the surgery." Autologous blood transfusion is the collection and reinfusion of the client's blood. With preoperative autologous blood donation, the blood is drawn from the client 3 to 5 weeks before an elective surgical procedure and stored for transfusion at the time of the surgery. Autologous blood is the safest form of blood transfusion because exclusive use of a client's own blood eliminates exposure to transfusion-transmitted infection. Incorrect: "Ask your provider to prescribe epoetin before the surgery." Epoetin is a hematopoietic growth factor used for the treatment of anemia. While taking epoetin prior to surgery can boost the client's hematocrit levels, it is inappropriate if the client already has an adequate hematocrit level. Furthermore, this action might not eliminate the need for a blood transfusion and its related risks. "You should ask your provider about taking iron supplements prior to the surgery." While taking an iron supplement prior to surgery can boost the client's hemoglobin levels, it is inappropriate if the client already has an adequate hemoglobin level and intake of iron from dietary sources. Furthermore, this action might not eliminate the need for a blood transfusion and its related risks. "Request a family member to donate blood for you." A blood donation from a family member does not eliminate the risk of acquiring an infection.

A nurse is teaching an assistive personnel [AP] about proper hand hygiene. Which of the following statements by the AP indicates an understanding of the teaching?

Correct: "There are times I should use soap and water rather than an alcohol-based hand rub to clean my hands." While alcohol-based hand rubs are as effective as soap and water in providing proper hand hygiene, the Center for Disease Control and Prevention recommends washing hands with soap and water at certain times, such as when the hands are visibly soiled with dirt or body fluids. Incorrect: "I will use cold water when I wash my hands to protect my skin from becoming too dry." Hand hygiene should be performed with warm water. Warm water preserves the protective oil of the skin better than hot water. "I will apply friction for at least 10 seconds while washing my hands." Friction is required to loosen and remove dirt and pathogens from the hands. To be effective, friction should be applied for at least 15 to 20 seconds. "After washing my hands I will dry them from the elbows down." Drying should be performed from the cleanest area (fingertips) to the least clean area (forearms) to prevent contamination of the newly cleaned hands.

A nurse is inserting an IV catheter for 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?

Correct: Carefully remove the gloves and follow with hand hygiene. Standard precautions require the use of gloves and hand hygiene in the care of all clients. Incorrect: Wash the gloved hands and then throw the gloves away. Washing the hands while still gloved is not a recommended action. Prepare an incident report to document the event. Unless there is a break in the nurse's skin, there is no need for an incident report or further investigation. Ask the provider to order a blood culture to determine the risk of infection. Unless there is a break in the nurse's skin, there is no need for further investigation.

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?

Correct: Lock the wheels on the bed and stretcher. Locking the wheels prevents the client from falling to the floor by not allowing the cart or bed to move apart or away from the client. incorrect: Instruct the client to raise his arms above his head. The nurse should ask the client to cross his arms across his chest to prevent injuring the arms during the transfer. Elevate the stretcher 2.5 cm (1 in) above the height of the bed. The stretcher should be no more than 1.3 cm (0.5 in) above the height of the bed. Log roll the client. Logrolling is a technique used to prevent injury when moving a client who requires immobilization of the neck, back, or spine. It is not indicated for a client following abdominal surgery.

A nurse is preparing a client who is scheduled for a hysterectomy for transport to the operating room when the client states she no longer wants to have surgery. Which of the following actions should the nurse take first?

Correct: Notify the provider about the client's decision. Acting as the client advocate, the nurse should support the client in her decision and notify the provider. Incorrect: Tell the client it is too late for her to change her mind because the surgery is already scheduled. The client has the right to refuse a procedure after giving consent. Telephone the operating room and cancel the surgery. This is not the responsibility of the nurse, but a decision the surgeon and the client must make. Inform the client's family about the situation. To respect the client's confidentiality, the family can be notified only after the client requests that the nurse do so.

A charge nurse is observing a newly licensed nurse perform a tracheotomy care for a client. Which of the following actions by the newly licensed nurse requires intervention?

Correct: Obtaining cotton balls for the tracheostomy care Cotton ball particles can be aspirated into the tracheostomy opening, possibly causing a tracheal abscess. The charge nurse should intervene for this action. Incorrect: Obtaining hydrogen peroxide for the tracheostomy care Half-strength peroxide solution is used to clean the inner cannula. Obtaining sterile gloves for the tracheostomy care Tracheostomy care is a sterile procedure requiring the use of sterile gloves. Obtaining a sterile brush for the tracheostomy care Pipe cleaners, or a small sterile brush, can be used to remove thick or crusty secretions from the inner cannula.

A nurse is assessing the heart sounds of a client who has developed chest pain that becomes worst with inspiration. The nurse asucultates a high-pitched scratching sound during both sytstole and diastole with the diaphragm of the stethoscope positioned at the left sternal border. Which of the following heart sounds should the nurse document?

Pericardial friction rub- A pericardial friction rub has a high-pitched scratching, grating, or squeaking leathery sound heard best with the diaphragm of the stethoscope at the left sternal border. A pericardial friction rub is a manifestation of pericardial inflammation and can be heard with infective pericarditis with MI, following cardiac surgery or trauma, and with some autoimmune problems such as rheumatic fever. The client who develops pericarditis typically has chest pain which becomes worse with inspiration or coughing and which may be relieved by sitting up and leaning forward. Audible click is a sound occurring in clients who have prosthetic valve replacements surgery. A heart murmur has a swishing or a whistling sound. Heart murmurs are caused by turbulent blood flow through the valves or ventricular outflow tracts. Low-and medium- frequency sounds are more easily heard with the bell of the stethoscope applied lightly to the skin; high-frequency sounds are more easily heard with a diaphragm. A murmur can be a manifestation of valvular disease. A third heart sound is a low-pitched sound after the second heart sound. An S3 is caused by rapid ventricular filling during diastole. It is best head at the mitral area, with the client lying on the left side. An S3 is commonly heard in children and young adults. In older adults and clients who have heart disease, an S3 often indicates HF.

A nurse is planning the care for a client who reports abdominal pain. An assessment by the nurse reveals the client has a temp of 102.6, HR of 105/min, a soft non tender abdomen, and menses overdue by 2 days. Which of the following findings should be the nurses's priority?

correct: Temperature Elevated temperature is an emergent physiological need, which requires priority intervention by the nurse. The nurse should consider Maslow's Hierarchy of Needs, which includes five levels of priority. The first level consists of physiological needs; the second level consists of safety and security needs; the third level consists of love and belonging needs; the fourth level consists of personal achievement and self-esteem needs; and the fifth level consists of achieving full potential and the ability to problem solve and cope with life situations. When applying Maslow's Hierarchy of Needs, the nurse should review physiological needs first. The nurse should then address the client's needs by following the remaining four hierarchal levels. However, it is important for the nurse to consider all contributing client factors, as higher levels of the pyramid can compete with those at the lower levels, depending on the situation. Incorrect: Heart rate 105/min This is an important assessment finding because the client's heart rate is elevated. However, fever and pain can contribute to tachycardia. This is not the priority finding. Soft, nontender abdomen This is an important assessment finding because of the client's report of pain. However, a soft nontender abdomen is an expected finding and should not cause concern. This is not the priority finding. Overdue menses This is an important assessment finding because of the client's report of pain. However, an irregularity in the menstrual cycle is a common finding when a client is stressed. This is not the priority finding.