Fundamentals Exam 3

A nurse is caring for a client newly diagnosed with sleep apnea. Which should the nurse teach the client about the most important reason why the continuous positive air pressure (CPAP) device should be used during sleep?

"The CPAP assures you get enough oxygen throughout the night."

The student nurse asks, "What is intravascular fluid?" What is the appropriate nursing response?

"Watery plasma, or serum, portion of blood."

A nurse is administering an injection of insulin to a 5-year-old who has type I diabetes. Which statement by the nurse would take into consideration this child's developmental level?

"You will just feel a little pinch."

What commonly used intravenous solution is hypotonic?

0.45% NaCl

A client with a complex cardiac history has been prescribed digoxin 0.0625 mg PO. The drug is available as 125 mcg tablets. How many of the tablets will the nurse administer?

0.5 1.0 mg = 1000 mcg. 0.125 mg =125 mcg. 0.0625 mg is exactly one half of 0.125 mg. If the digoxin tablet is 0.125 mg or 125 mcg, then the nurse would administer 0.5 tablet which is 0.0625mg, or 65.5mcg.

The nurse is teaching a first-time parent about the newborn's sleep needs. The nurse would inform the parent that newborns sleep approximately how many hours in a 24 hour period?

14 to 18 hours

The nurse is preparing to administer a tuberculin test. At which angle is the nurse expected to instill the drug?

15-degree angle

The nurse is teaching a healthy adult client about adequate hydration. How much average daily intake does the nurse recommend?

2,500 mL/day

A nurse is preparing to administer a rectal suppository to an adult client. How many inches (centimeters) should the nurse plan to insert the suppository?

3 in.

A health care provider orders an infusion of 250 mL of NS in 100 minutes. The set is 20 gtt/ml What is the flow rate?

50 gtt/mL The flow rate (gtt/min) equals the volume (mL) times the drop factor (gtt/mL) divided by the time in minutes.

A health care provider has asked the nurse to use microdrip tubing to administer a prescribed dosage of IV solution to a client. What is the standard drop factor of microdrip tubing?

60 drops/mL

A health care provider orders a bolus infusion of 250 mL of normal saline to run over 1 hour. The set delivers 20 gtt/mL. What is the flow rate in gtt/min?

83 gtt/min The flow rate (gtt/min) equals the volume (mL) times the drop factor (gtt/mL) divided by the time in minutes. 250 mL × 20 gtt/mL ÷ 60 min = 83 gtt/min

A client has a central venous catheter inserted. The nurse understands that the tip of the catheter would be found at which location? Select all that apply. A. Superior vena cava B. Right atrium C. Left ventricle D. Median cubital vein E. Basilic vein

A and B

The nurse is preparing a care plan for a client with disturbed sensory perception related to overstimulation. What would be appropriate goals for the client to achieve? Select all that apply. A. The client will state feeling rested after sleeping. B. The client will not fall during the hospital stay. C. The client will develop effective communication during the hospital stay. D. The nurse will use a communication board when speaking with the client. E. The nurse will assist the client with all ADLs during the hospital stay.

A, B, C

The nurse has received new medication orders for a client that has had a condition change. What components of the medication order's should be present prior to administering the medication? Select all that apply. A. the full name of the client B. the date and time when the order is written or placed in the order entry on the computer C. the brand name of the drug to be administered D. the dosage of the drug, stated in either the apothecary or metric system E. the route by which the drug is to be administered F. the signature of the nurse carrying out the order

A, B, D, E

The nurse is preparing to administer a bolus of an intravenous medication. How should the medication be administered?

All at once

A nurse who provides care in a long-term setting is aware of the need to promote and protect sensory stimulation for residents. What interventions should the nurse choose in order to achieve this goal? Select all that apply. A. Regularly assess residents for age-related sensory losses. B. Maintain a low-light environment to preclude sensory overload. C. Regularly reorient residents who are disoriented to person, place, or time. D. Ensure that residents who require assistive devices are regularly using them. E. Assess residents for the CNS effects of drugs and the potential for polypharmacy.

All the above

To meet the learning needs of the older adult, the nurse incorporates which considerations in planning to educate a 77-year-old client with diabetes about insulin administration?

Allowing extra time for the processing of the information

Altered sensory reception is a category of occurrences that can lead to sensory deprivation. Which scenario describes an example of altered sensory reception?

An 87-year-old woman is losing her eyesight. She is not able to leave her assisted living apartment without help. She is becoming more and more confused.

A client with a diagnosis of colon cancer has opted for a treatment plan that will include several rounds of chemotherapy. What vascular access device is most likely to meet this client's needs?

An implanted central venous access device (CVAD)

What is the lab test commonly used in the assessment and treatment of acid-base balance?

Arterial blood gas

When preparing to administer a second dose of a prescribed vaginal suppository, the client reports discomfort in the vaginal area. What should the nurse do next?

Assess the vaginal area

The nurse is caring for a client whose breast cancer necessitated a total mastectomy and lymph node dissection. The nurse will prioritize what assessment related to potential fluid and electrolyte imbalance?

Assessment for edema

A nurse is caring for a client who requires intravenous (IV) therapy. The nurse understands that which actions are the nurse's responsibilities related to this therapy? Select all that apply. A. Prescribing the kind of IV solution. B. Deciding the location of the IV catheter. C. Deciding the size of the IV catheter. D. Administering the IV solution. E. Determining the amount of IV solution.

B, C, D

A nurse is applying a nitroglycerine transdermal patch to a client. What is the preferred site to use?

Chest

A student has joined the marching band at high school and the band begins practicing outside during hot summer weather. Which health promotion guidance will the school nurse teach the student?

Consume commercial oral rehydration drinks on practice days

A client suffers from a genetic bleeding deficiency involving a deficit in factor VIII. Which blood product will the nurse most likely administer?

Cryoprecipitate

The nurse is performing an intake assessment of a 60-year-old client who admits to having a nightcap of 4 to 6 ounces of scotch whisky each night. What effect might this alcohol be having on the client's sleep?

Decreased REM sleep

A client is taking a diuretic such as furosemide. When implementing client education, what information should be included?

Decreased potassium levels

A client is experiencing slow-wave sleep. What assessment finding will the nurse identify as being consistent with this sleep stage?

Decreased temperature

A nurse inspecting a client's IV site notices redness and swelling at the site. What would be the most appropriate nursing intervention for this situation?

Discontinue the IV and relocate it to another site

A client is refusing to take his prescribed medication, stating that the government would then be able to track his whereabouts. What is the nurse's most appropriate action?

Document the client's delusion

The nurse is assessing an older adult client that reports feeling fatigued and tired throughout the day. What is the nurse's best action?

Have the client further evaluated for depression

A nurse is providing care to a client with hypocalcemia. The nurse would monitor the client's laboratory test results for which imbalance?

Hyperphosphatemia Calcium and phosphorus have a reciprocal relationship—if the calcium level is low, the phosphorus level would be high. A magnesium deficiency, not excess, may be accompanied by hypocalcemia. Sodium and potassium deficiencies are not typically associated with low calcium levels.

A nurse is reviewing the client's serum electrolyte levels which are as follows:Sodium: 138 mEq/L (138 mmol/L)Potassium: 3.2 mEq/L (3.2 mmol/L)Calcium: 10.0 mg/dL (2.5 mmol/L)Magnesium: 2.0 mEq/L (1.0 mmol/L)Chloride: 100 mEq/L (100 mmol/L)Phosphate: 4.5 mg/dL (2.6 mEq/L)Based on these levels, the nurse would identify which imbalance?

Hypokalemia All of the levels listed are within normal ranges except for potassium, which is decreased (normal range is 3.5 to 5.3 mEq/L; 3.5 to 5.3 mmol/L). Therefore, the client has hypokalemia.

A client with protracted nausea and vomiting has been receiving intravenous solution at 125 ml/h for the past several hours. The administration of this solution has resulted in an increase in blood pressure because the water in the solution has passed through the semipermeable membrane of blood cells, causing them to swell. What type of solution has the client been receiving?

Hypotonic solution

A client informs the nurse that she is not able to recall her phone number or address, and this is disconcerting. The nurse recognizes that the inability to recall information is indicative of which sensory/perception problem?

Impaired memory

The nurse is preparing to administer an allergy test via an intradermal injection. Which injection site would be most appropriate in this situation?

Inner surface of the forearm Sites commonly used for intradermal injections are the inner surface of the forearm and the upper back, under the scapula. The deltoid muscle of the shoulder is a common injection site for intramuscular injections. The abdomen and anterior aspect of the thigh are common injection sites for subcutaneous injections.

In which fluid compartment is most of the body's fluid is located?

Intracellular

To convert 0.8 grams to milligrams, the nurse should do which of the following?

Move the decimal point 3 places to the right

The client reports to the sleep clinic for a study following reports of sleepwalking and enuresis. Which sleep stage of non-rapid eye movement (NREM) sleep is affected based on the client's reports?

NREM delta The client who experiences sleepwalking (somnambulating) and enuresis (urinary incontinence) is likely in NREM stages 3 and 4, in which delta waves occur. NREM alpha, or stage 1, is the transition between drowsiness and sleep. NREM theta comprises 40% to 50% of total sleep time with rolling eye movements occurring. NREM kappa is not a sleep stage.

The nurse is caring for a client whose blood type is A negative. Which donor blood type does the nurse confirm as compatible for this client?

O negative Universal donor

A nurse working in a health clinic assesses sleep patterns during each health assessment. Based upon the nurse's knowledge regarding sleep needs, the nurse recognizes which age group as generally needing the least amount of sleep?

Older adults

A nurse is preparing to administer several prescribed medications to a client. The medications ordered are to be given by the following routes: oral, subcutaneous, intramuscular and intravenous. Place the routes in the proper order from slowest to fastest absorption. Subcutaneous Intramuscular Oral Intravenous

Oral Subcutaneous Intramuscular Intravenous

A new client in the medical-surgical unit reports difficulty sleeping and is scheduled for an exploratory laparotomy in the morning. The nurse identifies the nursing concern of altered sleep pattern with insomnia related to fear of impending surgery. Which step is most appropriate in planning care for this this client's nursing concern?

Provide an opportunity for the client to talk about concerns

A client has been receiving intravenous (IV) fluids that contain potassium. The IV site is red and there is a red streak along the vein that is painful to the client. What is the priority nursing action?

Remove the IV

A client's blood pressure has dropped from 146/92 mmHg to 107/68 mmHg over the course of several minutes. Increased levels of which of the following will be released into the client's bloodstream?

Renin

While administering a medication via a syringe, a client sharply moves and the nurse accidentally encounters a needlestick. What is the priority nursing action?

Report the needlestick to the nurse manager.

A nurse brings a client the prescribed dose of medication and finds that the client is not in the unit. What should the nurse do in this case?

Return the medication to the medication cart or medication room

An adultDocu client reports sleep latency of approximately 45 minutes each night. What is the nurse's best action?

Secure referrals for treatment of insomnia

The primary extracellular electrolytes include which of the following?

Sodium, chloride, and bicarbonate

A client begins snoring and is sleeping lightly. The stage of sleep is:

Stage 2 Stage 2 is relatively light sleep from which the client is easily awakened. Rolling eye movements continue, and snoring may occur.

The nurse is caring for a client receiving D5 ½ NS + 20 mEq KCl/L infusing per pump at 125 mL/hr. The nurse prepares to administer 40-mg furosemide IVP. Which actions should the nurse take? Select all that apply. Stop the infusion pump and clamp the line. Cleanse the infusion port closest to the pump. The first flush is at the same rate as the drug. Provide the medication at the recommended rate. The second flush is at the same rate as the drug.

Stop the infusion pump and clamp the line. Provide the medication at the recommended rate. The second flush is at the same rate as the drug.

The nurse is preparing a packed red blood cell transfusion for a client. The nurse checks the client's blood type in the electronic medical record (EMR) and notes that it is blood type B. What does this mean?

The client has anti-A antibodies.

How do you figure out drip rate of an IV?

The drip rate of an IV that is to infuse 1000 mL in 8 hours using a 10-gtt infusion set is 21 gtts/minute. The hourly rate is 125 cc/hr (1000 cc ÷ 8 hours). The volume of 125 cc equates to 1250 gtts (125 cc X 10 gtts/cc). The gtts/minute can be calculated by dividing 1250 gtts by 60 minutes. This yields 20.83 gtts which would be rounded to 21 gtts.

Which nursing strategy should the nurse employ to enhance the teaching/learning process for a client who is noncompliant with inhalers?

The nurse should provide simple written instructions with each medication.

The nurse is assessing a client and determines that they are in rapid eye movement (REM) sleep. What finding indicates to the nurse that the client is in this stage?

There is rapid eye movement under the eyelids

A nurse is caring for a client with scabies for which a topical medication has been prescribed. When educating the client on how to use the medication, which should the nurse tell the client regarding the application?

Use gloves to apply.

An automated medication-dispensing system has been introduced at healthcare facility, eliminating the need for two nurses to count controlled substances at the end of each shift. Which practice should the nurses on the unit perform to ensure accurate inventory of controlled substances?

Verify the count each time a medication is removed from the system

The nurse is preparing a care plan for a client recently diagnosed with obstructive sleep apnea. What lifestyle factor most likely has the ability to reduce the severity of the client's sleep apnea.

Weight loss

While injecting a needle into a client for an intramuscular injection, the nurse hits the client's bone. What would be the appropriate initial response of the nurse to this situation?

Withdraw the needle, apply a new needle to syringe, and administer the injection in an alternate site.

A nurse is reviewing the medication administration record. Which order does the nurse question?

a diuretic administered twice daily at 9 a.m. and 9 p.m.

A client tells the nurse that the client often has a difficult time falling asleep at night. What suggestion offered by the nurse may assist the client in achieving sleep?

a snack containing carbohydrates and protein

The nurse should obtain a sleep history on which clients as a protocol?

all clients admitted to a health care agency

A 4-year-old child's parent is employed and works from home. To accomplish their daily work, the parent allows the child to watch television for 6 to 8 hours per day. Based on this information, what nursing concern is applicable to this family?

altered parenting associated with failure to provide stimuli for growth

The nurse is completing an admission assessment for a client scheduled for back surgery after a construction accident. The nurse notes the client is having slowed speech and focus, irritability, yawning, and that he reports severe lumbar and right leg pain. The nurse suspects which primary nursing concern?

altered sleep pattern related to acute pain

Which client is at a greater risk for fluid volume deficit related to the loss of total body fluid and extracellular fluid?

an infant age 4 months

Which is a common anion?

chloride Anion = -

A client is receiving a secondary infusion of a new antibiotic through a peripherally inserted central line (PICC) suddenly reports itching and flushing. Which action should the nurse prioiritize for this client?

clamp the antibiotic infusion

A client has been admitted with fluid volume excess related to right-sided heart failure. Which assessment data would the nurse expect related to the fluid volume excess? Select all that apply.

crackles in the lungs, distended neck veins

A client who is NPO prior to surgery reports feeling thirsty. What is the physiologic process that drives the thirst factor?

decreased blood volume and intracellular dehydration

A nurse is assessing a client's state of awareness and finds the client to be disoriented and restless. The client is also agitated and alternates from confusion to excessive drowsiness to extreme excitability. The nurse would document this as:

delirium

During an assessment of an older adult client, the nurse notes an increase in pulse and respiration rates, and notes that the client has warm skin. The nurse also notes a decrease in the client's blood pressure. Which medical diagnosis may be responsible?

hypovolemia

The nurse is caring for a client with metabolic alkalosis whose breathing rate is 8 breaths/min. Which arterial blood gas data does the nurse anticipate finding?

pH: 7.60; PaCO2: 64 mm Hg (8.51 kPa); HCO3: 42 mEq/l (42 mmol/l) In metabolic alkalosis, arterial blood gas results are anticipated to reflect pH greater than 7.45; a high PaCO2 such as 64 mm Hg (8.51 kPa) and a high HCO3 such as 42 mEq/l (42 mmol/l). The numbers correlate with metabolic alkalosis, which is indicated by the hypoventilation and the retention of CO2. The other blood gas findings do not correlate with metabolic alkalosis.

The nurse is caring for a client who has normal saline infusing through a peripheral intravenous catheter with a prescription for a secondary infusion of antibiotic. Which technique would be most appropriate for the nurse to administer the secondary infusion by gravity?

placing the secondary infusion higher than the primary solution

A client with an infection is receiving intravenous antibiotic therapy. The client has an intermittent infusion device in place. The nurse flushes the device with normal saline solution before administering the antibiotic based on which rationale?

to prevent blood clot formation

The primary reason for the Controlled Substances Act is:

to prevent drug use and dependence.

The nurse makes the following assessment. A middle-age client reports falling asleep frequently at his job during the day, feels like he is not getting enough sleep at night (even though the number of hours of sleep is unchanged), continues to feel tired, and is not able to think clearly. Also, the client reports his wife believes he is irritable upon awakening. Nursing interventions include teaching the client to:

use caution when driving an automobile.

The client has been in the intensive care unit for several days. The client appears to be sleeping throughout the night. The nurse records the data listed above. The nurse evaluates that rapid eye movement (REM) sleep is occurring at:

0100 During REM sleep, the client's temperature, pulse, blood pressure, and respirations increase. The client may experience small muscle twitching, such as facial muscles twitching, and irregular pulse rate and respirations. During non-eye movement sleep, the client will exhibit a decrease in body temperature, pulse, blood pressure, and respirations.

The client has been in the intensive care unit for several days. The client appears to be sleeping throughout the night. The nurse records the data listed above. The nurse evaluates that rapid eye movement (REM) sleep is occurring at:

0100. During REM sleep, the client's temperature, pulse, blood pressure, and respirations increase. The client may experience small muscle twitching, such as facial muscles twitching, and irregular pulse rate and respirations. During non-eye movement sleep, the client will exhibit a decrease in body temperature, pulse, blood pressure, and respirations.

A client has been diagnosed with a gastrointestinal bleed and the health care provider has ordered a transfusion. At what rate should the nurse administer the client's packed red blood cells?

1 unit over 2 to 3 hours, no longer than 4 hours

The nurse is caring for a client with end-stage renal disease who voided 200 mL in the past 24 hours. The primary care provided ordered for a fluid restriction based on measurable urine output from the previous 24 hours added to insensible fluid losses. How much should the nurse provide for the 24-hour fluid allowance?

1,300

The nurse is preparing to administer meperidine as an intramuscular injection in an adult client's deltoid site. Which needle should the nurse select for this injection?

1-inch; 22-gauge IM injections using the deltoid site require a 20- to 25-gauge needle that is between 1 and 1½ inches (2.5 and 4 cm) in length.

The nurse is preparing to insert a short intravenous catheter in a 1-year-old child for a one-time administration of fluids due to dehydration. Which needle would the nurse likely select?

A 23-gauge winged infusion set Winged infusion or small vein needles may be used for short-term or one-time infusion therapies or may be used with infants and small children. These are short, beveled needles with plastic flaps or wings. A 19-gauge device would be too large for a one-year old client.

Which medication interaction illustrates a synergism?

A client takes acetaminophen to help her sleep. She also takes an oxycodone for pain related to recent hip surgery, which makes her even more drowsy. A synergistic reaction is one in which one drug increases the effect of another drug.

In which of the following clients will the nurse document the presence of delusions?

A client who believes the hospital kitchen staff are poisoning her food

A new prescription has been noted in the medical record for an adult client with chest pain to receive a medication that comes in the form of a transdermal patch. The nurse will consider which precaution(s) to ensure safety with this form of drug use? A. May cause injury with defibrillation. B. Fold the patch in half before disposal. C. Dispose of transdermal patches in the trash. D. Assess for fever prior to application. E. Apply patches at the same location for consistency. F. Remove the patch prior to magnetic resonance imaging (MRI). G. Monitor the client for early identification of adverse effects. H. Use a heating pad to increase absorption.

A, B, D, F, G

Which actions would a nurse perform when instilling eardrops correctly? Select all that apply A. Invert and hold the dropper in the ear with its tip above the auditory canal. B. Clean the external ear with cotton balls moistened with normal saline solution. C. Place the client on the affected side in bed. D. Draw up the amount of solution needed in the dropper and return any excess medication to the stock bottle. E. Straighten the auditory canal by pulling the cartilaginous portion of the pinna up and back in an adult (or down and back in an infant or child under 3 years). F. Hold the dropper in the ear with its tip above the auditory canal.

A, B, E, F

A nurse is administering an injection to a client at a 15-degree angle. The client has a venous access port. Which injection can be administered at this angle?

Intradermal

The nurse is caring for a client who just returned from the postanesthesia care unit and rates current pain as "9 out of 10." Which prescribed medication would provide the fastest relief from pain?

Intravenous morphine sulfate

The nurse is caring for a client on the acute care unit who experiences automatic behaviors associated with narcolepsy. What is the priority nursing intervention?

Keep the client safe by monitoring ambulation on the unit

A client calls the office and reports to the nurse that the prescribed medications are not working. What is the best response from the nurse?

Let's schedule an appointment for you to bring in all your medications.

The nurse is attempting to wake a client from sleep and is having a difficult time arousing them. What stage of sleep does the nurse identify the client is experiencing?

REM sleep

Which factor has the most influence on an individual's sleep-wake patterns?

The inner biologic clock

The plan of care for a client exhibiting signs of sensory deprivation includes incorporating tactile stimulation. Which nursing intervention will provide tactile stimulation?

providing a backrub with morning and evening care

The plan of care for a client exhibiting signs of sensory deprivation includes incorporating tactile stimulation. Which nursing intervention will provide tactile stimulation?

providing a backrub with morning and evening care Tactile stimulation includes backrubs, foot soaks, turning and repositioning, passive range-of-motion exercises, hugs, and touching. Orienting a client to his environment is cognitive input. Placing a calendar and clock on the client's bedside table is visual stimulation. Oral care is gustatory and olfactory stimulation.