Fundamentals Assessment

A nurse is reinforcing teaching about safety measures with the parent of 4 year old twins. Which of the following statements by the parent demonstrates and understanding of the teaching? A. "I dont need to worry about keeping the cabinets locked" B. "I can remove the car seats from the car now that my twins are 4 years old" C. "I will teach the twins to wash their own hands after using the bathroom" D. " i should have my twins immunized for the human papillomavirus before they start kindergarten"

" I will teach the twins to wash their own hands after using the bathroom"

A nurse is reinforcing teaching with an assistive personnel (AP) about proper body mechanics when moving a client. Which of the following instructions should the nurse include in the teaching? A. Maintain the client close to the body when transferring B. Keep legs and feet together when lifting the client C. Lean back at the hips to protect the lower back when lifting D. Twist at the waist when moving the client from the bed to the chair

A. Maintain the client close to the body when transferring

A nurse is caring for a client who has hypertension and a new prescription for atenolol. Which of the following findings is an adverse effect of the medication that the nurse should report to the provider? A. Hypersalivation B. Tachycardia C. Dizziness D. Urinary Retention

C. Dizziness

A nurse is preparing to administer a cleansing enema for a client. Which of the following actions should the nurse take? A. Fill the enema bag with 350 ml of warm tap water B. Position the client on their right side C. Insert the tip of the enema tube 10cm (4 in) D. Increase the rate of infusion if the client reports cramping

Insert the tip of the enema tube 10cm (4 in) Rationale: Slowly insert the rectal tube 7.5 to 10cm (3-4 in). For a child, insert the tube 5-7.5 cm (2-3in)

A nurse is reinforcing teaching with a newly licensed nurse about the use of mechanical restraints. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? A. "I should request a PRN prescription for a restraint" B. " I should attach the restraint to a nonmoveable part of the client's bed" C. "I should be able to insert three fingers under the restraint" D. "I should secure the restraint with a quick release buckle"

"I should secure the restraint with a quick-release buckle"

A nurse is contributing to the plan of care for a client who has a stage 3 pressure injury on the sacrum. Which of the following interventions should the nurse include? A. Keep the head of the client's bed at 45 degrees B. Apply a hydrocolloid dressing over the wound C. Reposition the client every 4 hr D. Cleanse the wound using cotton balls

B. Apply a hydrocolloid dressing over the wound

A charge nurse assigns a task to a newly licensed nurse. The newly licensed nurse acknowledges unfamiliarity with the tack. Which of the following attitudes of critical thinking is the nurse displaying? A. Risk taking B. Humility C. Discipline D. Perseverance

B. Humility Rationale: Humility means they acknowledge their weaknesses

A nurse is caring for a client who has dyspnea, fever, and a productive cough of thick, yellow sputum. Which of the following actions should the nurse take first? A. Perform nasotracheal suctioning on the client B. Obtain sputum cultures from the client C. Direct the client to turn, deep breathe, and cough frequently D. Administer an oral antibiotic to the client

B. Obtain sputum cultures from the client

A nurse is using a Snellen chart to collect vision data for a client who wears corrective lenses. Which of the following instructions should the nurse give the client? A. "Try to read the letters on a line that is blurry first" B. "Read the numbers out loud on the Snellen chart to test your near vision" C. "Cover one eye with an index card" D. "stand 10 feet away from the chart"

C. "Cover one eye with an index card"

A nurse is reinforcing teaching with the parent of a 2-year old child about nutrition. Which of the following information should the nurse include? A. "Limit milk intake to 4 cups per day" B. "Encourage an intake of 1/2 cup of vegetables per day" C. "Limit fruit juice to 4 ounces per day" D. "Encourage an intake of 3 ounces of protein per day"

C. "Limit fruit juice to 4 ounces per day" Rationale: you want to limit fruit juice to a toddle 4-6 oz a day.

A nurse is receiving a telephone call from a client's family member requesting information about the clients condition. Which of the following actions should the nurse take? A. Request that the family member contact the clients provider for information B. Gather additional information about the family members relationship to the client C. Determine if the client has given consent to share information with the family member D. Provide the family member with a general update on the clients condition

C. Determine if the client has given consent to share information with the family member

A nurse is caring for a group of clients on a medical-surgical unit. Which of the following tasks should the nurse delegate to an assistive personnel (AP)? A. Reinforcing teaching about use of an incentive spirometer B. Interpreting a blood glucose level C. Obtaining a stoll specimen D. Performing a sterile dressing change of an open wound

C. Obtaining a stool specimen

A nurse is caring for a client who has tuberculosis. Which of the following actions should the nurse take? A. Assign the client to a room with a roommate who has rubella B. Don gloves before coming into contact with the client C. Wear an N95 respirator when entering the client's room D. Place the client in positive airflow room

C. Wear an N95 respirator when entering the client's room

A nurse is reinforcing teaching about stress incontinence with a client. Which of the following statements by the client indicates an understanding of the teaching? A. "I will practice Kegel exercises while voiding" B. "I will increase my intake of citrus juices" C. "I will empty my bladder every 5 hours during the day" D. "I will use Crede's method when voiding"

D. "I will use Crede's method when voiding" Rationale:

A nurse is assisting in the development of an in-service about cultural sensitivity for clients who are experiencing pain. Which of the following information should the nurse include? A. Response to pain medications occurs equally across culture B. The client's tolerance of pain is dependent on the client's cultural background C. The nurse's cultural beliefs do not affect the response to a client's pain D. The use of numerical 0 to 10 pain scale is universal to all cultures

D. The use of numerical 0 to 10 pain scale is universal to all cultures