Fundamentals

A nurse is assisting with a presentation about caring for clients who are receiving diuretic therapy. The nurse should explain that which of the following medications can put clients at risk for hyperkalemia? ​ 1. Spironolactone 2. Furosemide 3. Hydrocholorothiazide. 4. Mannitol

1. Spironolactone.

A nurse has accepted a position on a pediatric unit and is learning more about psychosocial development. Identify the order of Erikson's stages of psychosocial development from birth through 18 years. ( move the step and select order) ​Trust vs. mistrust​ ​Initiative vs. guilt Identity vs. role confusion ​​Industry vs. inferiority Autonomy vs. shame and doubt

Trust vs. mistrust​ Autonomy vs. shame and doubt ​Initiative vs. guilt ​​Industry vs. inferiority Identity vs. role confusion

A nurse is caring for a client who is unconscious. With the help of an assistive personnel, the nurse has repositioned the client from a left lateral to a right lateral position. The client's daughter asks why the nurse keeps her father lying on his side. Which of the following rationales should the nurse give the family member? a. To allow full extension of the hip an knee joints. b. To prevent aspiration problems c. To promote lung expansion d. To prevent abdominal distention

b. To prevent aspiration problems

A nurse is participating in an interdisciplinary treatment meeting for a client who is to go home within a week. Which of the following health care providers should the nurse identify will assist the client with activities of daily living? 1. Occupational therapist. 2. Social worker 3. Recreational therapist. 4. Dietician

1. Occupational therapist.

A nurse is verifying that a client is giving informed consent to undergo electroconvulsive therapy. Which actions should the nurse take? 1. Confirm the client's signature is authentic. 2. inform the client of the adverse effect of the therapy 3. Discuss the benefits of the treatment with the client 4. Tell the client the purpose of the therapy

1. Confirm the client's signature is authentic.

A nurse is assisting in preparing a presentation at a senior center about age-related musculoskeletal changes. Which of the following alterations is appropriate for the nurse to include? 1. Decreased muscle mass 2. Thickened vertebral disk 3. Decrease chest width 4. Increased force of isometric contraction

1. Decreased muscle mass

A nurse is contributing to the plan of care for a client who has a gastrostomy tube through which he is receiving continuous enteral feedings. Which of the following interventions should the nurse include in the plan? 1. Flush the tube with 30 mL of water every 4 hr. 2. Keep the head of the bed elevated at 15 degree. 3. Change the feeding bag and tubing every 72 hr. 4. Place enough formula in the feeding bag to last for 8 hr of continuous feeding

1. Flush the tube with 30 mL of water every 4 hr.

A nurse is caring for a group of client on a medical surgical unit. Which of the following actions jeopardize client confidentiality? (SATA) 1. Sharing a personal password with a coworker 2. Discussing clients a the table in the cafeteria 3. Giving verbal report a change of shift in a designated conference room 4. Removing client information from fax machine immediately 5. Disposing of written report sheet into the facility trash receptacle.

1,2,5

A nurse is reinforcing teaching with a client about the use of transcutaneous electrical nerve stimulation (TENS) to manage chronic pain. Which of the following statements by the client indicates the need for further teaching? 1. "It's unfortunate that I have to be in the hospital for this treatment." 2. " I wish I didn't have to attach the electrodes to my skin" 3. "I will need to shave the hair off the skin where I place the electrodes" 4. " I hope I don't have to take as many pain pills"

1. "It's unfortunate that I have to be in the hospital for this treatment."

A nurse is reviewing a provider's prescriptions for a group of clients. Which of the following client prescriptions should the licensed practical nurse (LPN) clarify with the provider? 1. Administer 1 g of vancomycin intrathecally. 2. Insert an indwelling urinary catheter if bladder scan is greater than 500 ml 3. Perform sterile dressing change on leg wound 4. Reinforce teaching about foot care for type 1 diabetes mellitus

1. Administer 1 g of vancomycin intrathecally.

A nurse is caring for a client who has a stage-3 pressure ulcer that now has some granulating tissue. Which of the following interventions should the nurse recommend for inclusion in the plan of care? 1. Cleanse with 0.9% sodium chloride irrigation. 2. apply a heat lamp twice a day 3. cleanse with providone-iodine solution 4. Massage reddened areas during dressing changes.

1. Cleanse with 0.9% sodium chloride irrigation.

A nurse is preparing to help with transferring a client who can partially assist to a gurney. Which of the following actions should the nurse take? 1. Lower the head of the bed. 2. Place the bed in its lowest position 3. Unlock the wheels on the bed 4. Have two caregivers at the side of the bed

1. Lower the head of the bed

The RN has just received a client who is schedule for a subtotal thyroidectomy. The RN has just delegated to the LPN to receive the client. Which of the following interventions would the LPN defer to the RN to perform? 1. Provide client education. 2. Organize in the room , necessary equipment 3. provide hospital attire and assist as needed 4. Apply the identification bracelet and allergy band if needed.

1. Provide client education.

A nurse is contributing to the plan of care for a client who has a pressure ulcer on his heel. Which of the following information should the nurse include in the plan? 1. Provide the client a diet high in vitamin C. 2. Keep the ulcer bed dry 3. Clean the wound bed with hydrogen peroxide. 4.Reposition client at least every 4 hr.

1. Provide the client a diet high in vitamin C.

A nurse is discussing indications for urinary catheterization with a newly licensed nurse. Which of following indications should the nurse include? (SATA) 1. Relief of urinary retention 2. Measurement of residual urine after urination 3. Presence of an open perineal wound 4. convenience for the nursing staff or the client's family 5. Routine acquisition of a urine specimen

1. Relief of urinary retention 2. Measurement of residual urine after urination 3. Presence of an open perineal wound

A nurse is planning to perform passive range of motion for a client who is immobilized. Which of the following actions should the nurse plan to take? 1. Support extremities above and below joints. 2. Move body parts rapidly through the movement 3.Strecth the body part just beyond the existing rang of motion 4. Continue moving body parts if muscle spasticity occurs.

1. Support extremities above and below joints.

A nurse is collecting data from a client who has hypokalemia as a result of nausea, vomiting, and diarrhea. Which of the following findings should the nurse expect? 1. Weak, irregular pulse 2. Hyperactive reflexes 3. Extreme thirst 4. Hyperactive bowel sounds.

1. Weak, irregular pulse

A nurse is reinforcing teaching to a group of older adults about sources of complete and incomplete protein. Which of the following foods should the nurse include as a complete protein? 1. Yogurt 2. Fresh vegetables 3.Nuts 4. dried bean

1. Yogurt

A nurse is caring for a client who has urinary incontinence. Which of the following actions should the nurse take to prevent the development of skin breakdown? 1. apply a moisture barrier ointment to the skin 2. Clean the skin and perineum with hot water after each episode of incontinence 3. Check the client's skin every 8 hr for sign of breakdown 4. Request a prescription for the insertion of an indwelling urinary catheter.

1. apply a moisture barrier ointment to the skin

A nurse is assigned care of a client who has HIV. Which of the following infection control precautions should the nurse plan to use while caring for this client? 1. standard precaution 2. Airborne precaution 3. contact precaution 4. Droplet precaution

1. standard precaution

A nurse is caring for a client who is Hindu and adheres strictly to the traditional dietary laws of this religion. The client has no other dietary restrictions. Which of the following foods should the nurse select as a component of the client's meals? 1. Steamed vegetables 2. a hamburger 3. A cheese omelet 4. a bologna sandwich

1. steamed vegetables.

A nurse is assisting with the preparation of a presentation at a community center about complementary and alternative therapies. Which of the following therapies should the nurse describe as the use of an electronic monitoring device to help clients learn to control physical responses? 1. Reiki 2. Biofeedback 3. Acupuncture. 4. Yoga

2. Biofeedback

A client with pneumonia is experiencing respiratory distress. The order states, "if respiratory distress occurs, apply a face mask with precise concentration of oxygen". Which of the following masks delivers precise oxygen concentration? 1. Partial rebreather mask 2. Venturi mask 3. Non-rebreather mask 4. Aerosol mask

2. Venturi mask

A nurse working on a medical-surgical unit suspects that several clients have Clostridium difficile (C. difficile) when they all develop watery diarrhea. Which of the following actions should the nurse plan to take while waiting for the client's lab results? 1. obtain stool culture from all client on the nursing unit 2.Place all client who have manifestation on contact precaution 3. Perform hand hygiene with an alcohol based agent 4. Request the provider to initiate antibiotic therapy for every client on the unit.

2.Place all client who have manifestation on contact precaution

A nurse is caring for an older adult client who has constipation. Which of the following actions should the nurse take? 1. Request that the provider prescribe a stool softener 2. Promote active range of motion activities 3. Add fluid and fiber to the diet 4. Avoid gas-producing foods.

3 add fluid and fiber to the diet

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? 1. " I should have grab bars installed in my bathroom" 2. " I should leave a night light on when I go to bed a night" 3. " I should use my walker carefully when going upstairs" 4. " I should have my son change the batteries in my smoke detetors each years.

3. " I should use my walker carefully when going upstairs"

A nurse is caring for a client who presents to an urgent care with a laceration on his forearm. Which of the following activities is an example of primary prevention? 1. Suturing the client's wound 2. Applying a sterile dressing 3. Administering a tetanus immunization 4. Teaching the client about follow-up care

3. Administering a tetanus immunization

A nurse is planning to perform passive range of motion for a client who is immobilized. Which of the following actions should the nurse plan to take? 1. Spending extra time to calm an agitated client 2. Describing the adverse effects of a client's medication 3. Supporting a client's wishes to refuse prescribed treatment. 4. Ensuring that a client understands expectation for group participation

3. Supporting a client's wishes to refuse prescribed treatment.

A nurse is collecting data from a client who has venous insufficiency. Which of the following findings should the nurse expect? 1. Dusky , red color or the feet when dangling 2. Shiny, thin skin on the lower extremities 3.Thicknened toenailes 4. Pitting edema

4. Pitting Edema

A nurse in a long-term care facility enters the day room and finds the window curtains on fire. Clients are panicking and the room is filling with smoke. Indicate the emergency actions the nurse must take ( select order , use all the step) Remove the clients from the room. Activate the fire alarm. Close the door.​ Extinguish the fire.

Remove the clients from the room. Activate the fire alarm. Close the door.​ Extinguish the fire.