Fundamentals Exam B
A nurse is caring for a client with a diagnosis of terminal cancer. What statement from the client indicates that the client is ready to hear information regarding palliative care?
"I want you to tell me about measures available to keep me comfortable."
A middle adult tells the nurse, "I feel so useless now that my children do not need me anymore." How should the nurse respond?
"People in middle adulthood often find satisfaction in nurturing and guiding young people." this focuses the patient on what they can do about how they feel and leads to nurse to help the pt explore opportunities for mastering the developmental tasks of their life stage
A nurse is caring for a client who is schedules to be transferred to a long term care facility. The client's family questions the nurse about the reasons for the transfer. How should the nurse respond?
'Would you like it if we discussed the transfer with your family member?" this facilitates therapeutic communication and provides leads while maintaining client confidentiality
What is the normal creatinine level?
0.5 to 1.1 mg/dL
What is the normal BUN level?
10 to 20 mg/dL
How many air exchanges does a protective environment have?
12 per hour
What is the normal level of sodium in the blood?
136-145 mEq/L
How often should the nurse remove a client's wrist restraints to evaluate the client's overall status?
2 hours
What is the normal potassium level?
3.5 to 5 mEq/L
What size should the syringe be when the nurse performs open irrigation on a client's indwelling urinary catheter?
30 to 50 mL syringe
At what age should adult clients receive the shingles vaccine?
60 years old
At what age should adult clients receive the pneumococcal vaccine?
65 years old
What percentage of the adult patient's arm circumference should the BP cuff's bladder surround to give an accurate reading?
80%
A nurse is caring for a client who has a nasogastric tube and is receiving intermittent feedings through an open system. Which of the following actions should the nurse take first? A) rinse the feeding bag with water between feedings B) tell the client to keep the head of the bed elevated at least 30 degrees C) make sure the enteral formula is at room temp D) Wipe the top of the formula can with alcohol
B) tell the client to keep the head of the bed elevated at least 30 degrees -this is because the nurse should prioritize airway first with the ABC approach. The client could aspirate if enteral formula refluxes into the esophagus
What question should the nurse ask when determining the location of a patient's pain?
Does the pain radiate?
What question should the nurse ask when determining the onset, duration, and pattern of a patient's pain?
Is your pain constant or intermittent?
What actions should the nurse take after confirming the presence of a fire?
RACE, rescue clients, activate alarm, confine fire (close doors and windows, turn off oxygen and electrical equipment), extinguish fire
What question should the nurse ask when determining the intensity of a patient's pain?
What would you rate your pain on a scale of 0 to 10?
What is a normal finding in a patient that has hyponatremia?
abdominal cramping, weakness, confusion, lethargy, headache, nausea
How much urine should a client with an indwelling catheter produce per hour?
at least 30 to 50 mL/hr
What kind of patients is the FLACC pain rating scale used for?
children 2 months to 7 years old
What is an example of a disinfectant that would kill spores?
chlorine bleach
What is the goal of palliative care?
comfort and manifestation control
A nurse is admitting a client who has an abdominal wound with a large amount of purulent drainage. What type of transmission precaution should the nurse initiate?
contact precautions with a private room, caregivers should wear gown and gloves
How often should a client who is receiving supplemental oxygen inspect their oxygen equipment?
daily
A middle adult tells the nurse, "I feel so useless now that my children do not need me anymore." How should the nurse NOT respond?
do not minimize the client's feelings, do not imply that the pt should be proud of their children's independence, do not ask "why" questions as they can seem accusatory
A nurse is caring for a client who is schedules to be transferred to a long term care facility. The client's family questions the nurse about the reasons for the transfer. How should the nurse NOT respond?
do not respond defensively, ask a why question, or sympathetically as these types of responses can interfere with a therapeutic relationship
How often should the nurse evaluate a client's circulation, ROM, vital signs, and overall status after the initial application of wrist restraints?
every 15 minutes
How often should older adults have eye examinations?
every year
What is a positive chvostek's sign a manifestation of?
hypomagnesemia and hypocalcemia
What deficiency is tachycardia a manifestation of?
hyponatremia and hypovolemia
What does the herbal supplement ginkgo biloba do?
improve memory and reduce stress
What does metoclopramide do?
increases GI motility and prevents N/V
Should the nurse keep their feet close together when lifting an object?
no, should spread feet wide apart to create a broad base of support to promote stability
Should the nurse bend at the waist when lifting an object?
no, the nurse should bend the knees
A nurse is caring for a client who is receiving pain medication through a PCA pump. Should the nurse instruct the client to avoid pushing the button until pain is above a 7 on a scale of 0 to 10?
no, the nurse should just instruct the patient to activate the pump when they need it
Should a client who is receiving supplemental oxygen use wool blankets on their bed?
no, they should use cotton blankets to avoid generating static electricity that could ignite the oxygen
Should the nurse wear a surgical mask when providing care for a patient with tuberculosis?
no, they should wear an N95 respirator
A nurse is caring for a client with an indwelling urinary catheter. Does the urine having an unusual odor indicate the need for irrigation?
no, this can be a sign of infection but will not be treated by irrigation
Should the nurse massage areas of skin on the patient that are darker with unscented lotion to prevent skin breakdown?
no, this can cause further capillary breakdown in subcut tissues
For a 24 hr urine collection, can the client save a specimen in the bathroom for 30 minutes?
no, urine should be immediately but in the container and kept on ice or in the fridge
A nurse is caring for a client who is postoperative and exhibiting signs of hemorrhagic shock. The nurse notifies the surgeon, who tells the nurse to continue to measure the client's vitals every 15 min and report back in 1 hr. What action should the nurse take first?
notify the nursing manager to activate the chain of command to ensure the client receives the necessary care
What steps should the nurse take when performing post mortem care, in order?
obtain pronouncement of death from provider, remove tubes and indwelling lines, wash client's body, ask client's family members if they would like to view the body, place name tag on body
What does the herbal supplement echinacea do?
promotes immunity and reduces infection risk
Why should a client who reports difficulty falling asleep NOT watch TV in bed before sleep?
to reduce stimulate and promote rest
Can both fluid volume excess and deficit cause tachycardia?
yes
Is it important for a client who is receiving supplemental oxygen to know where the fire extinguisher is?
yes, oxygen is very flammable
A nurse enters a client's room and finds them on the floor. The client's roommate reports that the client was trying to get out of bed and fell over the side rail onto the floor. What should the nurse document about this incident?
"Client found lying on the floor." this information is descriptive and objective, it does not include any opinions or judgements about motives or cause
A nurse is assessing a client's readiness to learn about insulin self-administration. Which of the following statements should the nurse identify as an indication that the client is ready to learn?
"I can concentrate best in the morning." the client is verbalizing the best time for them to learn
What should the nurse tell a client who is requesting information about advance directives in order to address the client's needs in a direct and simple way?
'We can talk about advanced directives, and I can also give you some brochures about them."
What question should the nurse ask when determining the quality of a patient's pain?
Is your pain sharp, dull, crushing, throbbing, aching, burning, electric-like, or shooting?
What should happen to RR and HR if the nurse administers 1L of 0.9% NaCl to a pt that has fluid volume deficit?
RR and HR should decrease to the expected range
What are three examples of tasks a nurse can assign to an AP?
assist client with partial bed bath, measure client's BP after nurse administers antihypertensive medication, use communication board to ask client what they want to eat
A nurse is caring for a client who is having difficulty breathing. The client is supine and is receiving supplemental oxygen via nasal cannula. What intervention should the nurse take first?
assist the client into an upright position as it is the least invasive, assists in chest expansion, and increases the effectiveness of the existing supplemental oxygen
When assessing an adult client's abdomen, should the nurse auscultate bowel sounds or palpate the abdomen first?
auscultate first as not to change the character of the sounds by palpating
A nurse is initiating a protective environment for a client who has had an allogenic stem cell transplant. What is a precaution the nurse should plan for this client?
client should wear mask outside of room if there is construction in area, this is bc allogenic stem cell transplant compromises client immune system and increases risk for infection
Who is eligible to receive the pneumococcal vaccine?
clients must be 19 and older, but eligibility is based on if the client is 65 and older and or has certain conditions such as chronic heart, lung, or liver disease, DM, have alcohol or smoking dependency
Why should a client who reports difficulty falling asleep NOT drink hot cocoa before bed?
cocoa contains the stimulant caffeine and can interfere with sleep
A nurse is caring for a client who has diarrhea due to shigella. What precautions should the nurse implement for this client?
contact precaution to prevent bacteria transmission, nurse should wear gown when providing care
What precautions should the nurse take when preparing for the surgical procedure of a client with a latex allergy?
cover monitoring cords with nonlatex barrier (like stockinette) and secure them with nonlatex tape
What are some indications of fluid volume excess?
distended neck veins, edema, tachycardia, crackles in lungs, dyspnea, bounding pulse, increase in BP
How often should older adults receive a tetanus booster?
every 10 years
At what intercostal space is the PMI (apical HR) located?
fifth intercostal space at midclavicular line left of sternum
What is a findings would confirm correct NG tube placement?
gastric aspirate is 5 or less, x ray shows rube above pylorus
What is Erik Erikson's theory about the task of middle adulthood?
generativity vs. self absorption and stagnation, the middle adult should offer support and guidance to future generations and may feel fulfilled by volunteering and mentoring young people
What dressing should the nurse apply for a patient who has a stage 2 pressure injury and why?
hydrocolloid, it promotes healing in stage 2 pressure injuries by creating a moist wound bed
What deficiency is numbness of the extremities a manifestation of?
hyperkalemia
What are some indications of fluid volume deficit?
hypotension, weak thready pulse, slow capillary refill, tachycardia dry mucous membranes, sunken eyeballs, increased hematocrit and urine specific gravity, dark yellow urine and or urine output less than 30 mL/hr
Why should a client who reports difficulty falling asleep NOT exercise 1 hour before going to bed?
it can interfere with sleep because it rises temp and HR
A nurse is caring for a client who reports difficulty falling asleep. What recommendation should the nurse make and why?
maintain a consistent time to wake up each day, establishes internal sense of sleep and waking on daily basis, promotes sleep
What is the difference between negative and positive air pressure isolation rooms?
negative keeps pathogens in, positive keeps pathogens out
Does the nurse have to wear an N95 respirator mask when caring for clients who require airborne precautions?
no
Should the nurse limit a client's (who has shigella) time with visitors?
no it will not decrease risk of spread and can put pt at risk for depression and loneliness
Should the nurse assign a client with shigella to a negative pressure airflow exchange room?
no only private room, negative pressure airflow not necessary because shigella is not airborne
Should the nurse assign a patient with C diff to a room with a negative airflow system?
no, C diff is not airborne
Should the nurse increase the client's intake of carbs to prevent skin breakdown?
no, but increased protein with help with tissue repair and a balanced diet with adequate fluid intake can help prevent skin breakdown
Should the nurse cleanse latex ports on IV tubing with chlorhexidine before injecting meds for patients with latex allergies?
no, cleansing a latex item will not remove latex protein, nurse should use a stopcock to inject meds
Should the nurse use ethylene oxide to sterilize nondisposable latex items for patients with latex allergies?
no, ethylene oxide can cause allergic reactions in clients who have latex allergy, nurse should rinse items that were sterilized with this before use
A nurse is caring for a client who is receiving pain medication through a PCA pump. Should the nurse take this client's vital signs every 8 hr?
no, every 1 to 2 hr during the first 12 hr, this reduces the pt risk of respiratory depression
A nurse is caring for a client with an indwelling urinary catheter. Does the urine being positive for ketones indicate the need for irrigation?
no, it indicates DM with poor glucose control but will not be treated by irrigation
A client after abdominal surgery immediately has hypoactive bowel sounds. An hour later, the client reports nausea and the nurse administers metoclopramide 10 mg IV bolus. 30 minutes later the client reports relief from nausea. Should the nurse report these gastrointestinal assessment findings to the provider and why?
no, nausea and hypoactive bowel sounds were initially noted but client reports relief after metoclopramide administration
Should the nurse use a tongue depressor for a client who is having seizures?
no, nurse should not insert anything into the mouth of a client who is having a seizure as to not increase risk for injury to mucous membranes and teeth
Should a client who is receiving supplemental oxygen store an oxygen tank on its side under their bed?
no, oxygen tanks should be stored upright
Should the nurse clean surfaces potentially contaminated with C diff with phenol solution?
no, phenol works for bacteria and fungi but not C diff spores
A client after abdominal surgery is oriented to person, place, and time. They are able to move all extremities. Should the nurse report these neurological findings to the provider and why?
no, pt is A&Ox3, has no indication of neurological compromise
Should the nurse place a client in supine position during seizure activity?
no, pt should be turned to the side to prevent choking from the tongue and secretions
Should the nurse have a client with shigella wear a mask when receiving visitors?
no, shigella is not airborne or droplet
Should the nurse instill 15 mL of irrigation fluid into a client's indwelling urinary catheter to perform open irrigation?
no, should be 30 to 40 mL
Should the nurse place the client in a side lying position to perform open irrigation on their indwelling urinary catheter?
no, should be supine or dorsal recumbent
Should the nurse use the back muscles for lifting an object?
no, should use arm and leg muscle because they are stronger
A client after abdominal surgery has a abdominal dressing. While the initial assessment indicated drainage on the dressing, there has been no further drainage since that time. Should the nurse report these incisional drainage findings to the provider and why?
no, small amount of drainage following abdominal surgery is expected finding, does not need to be reported unless drainage continues or increases over time
Should the nurse use hypoallergenic gloves that contain powder when caring for a patient with a latex allergy?
no, these gloves still contain latex and provoke an allergic response
Should the nurse apply restraints on a client who is having frequent tonic-clonic seizures?
no, this increases their risk for injury
Should the nurse document the completion of an incident report in the client's medical record?
no, this is for the facility's protection in the event of litigation
A nurse is caring for a client who is receiving pain medication through a PCA pump. Can the nurse increase the basal rate and shorten the lock out interval time if the client's pain level is too high?
no, this is not within the nurse's scope of practice
A nurse is caring for a client with an indwelling urinary catheter. Does the urine's specific gravity being 1.035 indicate the need for irrigation?
no, this means the urine is too concentrated but will not be treated by irrigation
Should the nurse place a patient in high fowler's position to prevent skin breakdown?
no, this position puts pressure on the sacrum and heels which increases risk for skin breakdown
Can the nurse delegate an AP to confirm a client's pain has decreased after receiving an analgesic?
no, this requires advanced nursing knowledge
Can the nurse delegate demonstration of the use of an incentive spirometer to an AP?
no, this requires advanced nursing knowledge
Can the nurse delegate insertion of an indwelling catheter to an AP?
no, this requires nursing judgement and sterile technique
Should the nurse use alcohol based sanitizer to clean their hands after caring for a patient with C diff?
no, this sanitizer will not kill C diff spores, nurse should use soap and water
Can the nurse assign an AP to irrigate the client's indwelling urinary catheter?
no, this task is an invasive procedure not in an AP's scope of practice
Can the nurse assign an AP to test a client's swallowing ability by providing thickened liquids?
no, this task requires assessment and places the client at risk for aspiration
For a 24 hr urine collection, can the client have a bowel movement but save the urine?
no, urine should be free of feces
A nurse is planning care of an adolescent who is postoperative following a lumbar laminectomy. What are some interventions the nurse include in the plan of care?
nurse should encourage visitors and allow the adolescent to make decisions regarding their food choices, daily routine, and personal hygiene to maintain independence
A nurse is caring for a client who has a new prescription for wrist restraints. What action should the nurse take?
pad the client's wrists before applying the restraints to keep the skin from breaking down
What actions should the nurse take when caring for a client who has tuberculosis?
place client in negative air pressure room for airborne precaution, wear gloves when assisting with oral care for standard precautions, use antimicrobial sanitizer for routine hand hygiene and wash hands with soap and water when they are visibly soiled
A nurse is caring for a client who is having difficulty breathing. The client is supine and is receiving supplemental oxygen via nasal cannula. Should the nurse instruct the client to perform incentive spirometry every hour?
potentially, this can help ease the client's breathing by expanding smaller airways and alveoli, but the nurse should assist the client to sit up first
A nurse is caring for a client who is having difficulty breathing. The client is supine and is receiving supplemental oxygen via nasal cannula. Should the nurse humidify the client's supplemental oxygen?
potentially, this can help to thin secretions that could limit airflow, but the nurse should assist the client to sit up first
A nurse is caring for a client who is having difficulty breathing. The client is supine and is receiving supplemental oxygen via nasal cannula. Should the nurse suction the client's airway?
potentially, this can remove pulmonary secretions and ease the client's breathing, but the nurse should assist the client to sit up first
What does the herbal supplement feverfew do?
promotes wound healing and decreases inflammation associated with arthritis
What lab values may be slightly different for a client with hypovolemia?
raised BUN, raised creatinine, lowered sodium
What do the the herbal supplements valerian and chamomile do?
reduce anxiety
What does the herbal supplement ginger do?
relieve nausea and vomiting and aid in digestion
What are some examples of conditions that require droplet precautions?
rubella, meningococcal pneumonia, streptococcal pharyngitis
What stage pressure wounds do transparent dressings treat and why?
stage 2, they prevent further friction and shearing
What stage pressure wounds do alginate dressings treat and why?
stage 3 and 4, alginate forms soft gel when it comes in contact with drainage
What stage pressure wounds do moistened gauze dressings treat and why?
stage 4 and unstageable, they cause debridement and allow granulation of the wound bed
Where should the nurse secure restraint ties?
to a part of the bed frame that moves with the client to reduce risk of injury
What are some examples of conditions that require airborne precautions?
tuberculosis, measles
What are some examples of pain rating scales appropriate for adult clients?
visual analog scale, numerical scale
A nurse is caring for a client who is refusing a blood transfusion for religious reasons. The client's partner wants the client to have the transfusion. What should the nurse do?
withhold the blood transfusion, the principle of autonomy ensures that a client who is competent has the right to refuse treatment
Should the nurse have the family members visiting a patient with C diff wear a gown and gloves?
yes, C diff has contact precautions
For a 24 hr urine collection, should the client flush what they urinated at 7am and save all urine since?
yes, client should discard first voiding and save subsequent voidings
Should the nurse subtract the amount of irrigant used from the client's urine output after performing open irrigation on a client's indwelling urinary catheter?
yes, fluid used for irrigation should be subtracted from the client's total urinary output
A client after abdominal surgery has a the following vitals at 1100: temp 97.2, HR 76, RR 18, BP 122/68, SpO2: 95% on room air. The client then has the following vitals at 1200: temp 98.2, HR 116, RR:20, BP 112/68, SpO2: 93%. Should the nurse report these vital signs to the provider and why?
yes, pt HR and RR have increased, O2 sat and BP have decreased
A client after abdominal surgery has an indwelling catheter. An hour after surgery, the urine output is 15mL. 30 minutes after that, there has been no urine output. Should the nurse report these urinary output findings to the provider and why?
yes, pt should be producing a least 30 to 50mL/hr of urine with indwelling catheter, since pt is producing less than expected volume nurse should check catheter placement for blockage and report to provider
A client reports pain on a scale of 6 out of 10 an hour after abdominal surgery and is given morphine 4 mg IV bolus. 30 minutes later the pain has increased to 8 out of 10. Should the nurse report these reported pain findings to the provider and why?
yes, pts pain has not been relieved by morphine and pain is increasing
A nurse is caring for a client with an indwelling urinary catheter. Does a bladder scan showing 525 mL of urine indicate the need for irrigation?
yes, since the pt has a indwelling catheter there should be a continuous flow of urine with no accumulation in the bladder, irrigation should resolve potential blockage
Should the nurse expect tachycardia from a client that has reported vomiting and diarrhea for the past 3 days?
yes, tachycardia is a manifestation of fluid volume deficit which is expected in this case
Should the nurse report a potassium of 5.8 to the provider and why?
yes, this affects the contractility of the heart and could put the pt at risk for developing dysrhythmias
A nurse is caring for a client who is receiving pain medication through a PCA pump. Should the nurse instruct the patient's family to refrain from pushing the button for the patient while they are asleep?
yes, this decreases the risk of overdose
Can the nurse delegate an AP to ambulate a client who is postoperative?
yes, this does not requires special skills, assessment, or teaching
Does having a client use a trapeze bar when changing position help prevent skin breakdown?
yes, this helps avoid friction and shearing that results from sliding up and down in bed
Should the nurse stand close to an object when lifting it?
yes, this keeps the cabinet close to the nurse's center of gravity and decreases back strain from horizontal reaching
Should the nurse wrap blankets around all four sides of the bed for a patient who is having frequent tonic-clonic seizures?
yes, this pads the bed and prevents injury
A nurse is caring for a client who has a nasogastric tube and is receiving intermittent feedings through an open system. Should the nurse rinse the feeding bag with water between feedings?
yes, this reduces risk of bacterial growth
A nurse is caring for a client who has a nasogastric tube and is receiving intermittent feedings through an open system. Should the nurse make sure the enteral formula is at room temp?
yes, this will prevent cramping and discomfort that can result from instilling cold formula
A nurse is caring for a client who has a nasogastric tube and is receiving intermittent feedings through an open system. Should the nurse wipe the top of the formula can with alcohol?
yes, this will remove/disinfect dirt or pathogens that could contaminate the formula