Fundamentals Exam B

A nurse is assisting with the admission of an older adult client to an acute care facility. The client states that she is afraid to go to sleep, fearing she will not wake up. Which of the following is a therapeutic response the nurse should make? 1. "I will have the nursing staff check on you frequently during the night." 2. "You are right to be afraid. This is a new place for you. 3. "I will give you you prescribed sleeping medication to help you fall asleep." 4. "Describe your concerns about sleeping to me.

"Describe your concerns about sleeping to me"

A nurse is contributing to the plan of care for a client who is dying. Which of the following interventions should the nurse recommend to include the client's family in the plan of care? (Select all that apply) 1. Keep the family updated about the client's status 2. Suggest that family members return home at night to allow client to rest 3.Encourage the family to comb the client's hair 4. Tell the client's family what to expect as the client's death nears. 5. Ask the family to encourage the client to eat.

*Keep the family updated about the client's status *Encourage the family to comb the client's hair * Tell the client's family what to expect as the client's death nears

A nurse is providing oral hygiene for a client who is unconscious. Identify the sequence of the steps the nurse should take.

1. Assess the client's gag reflex 2. Position the client on his side with his head turned to the side 3. Place a towel under the client's head with an emesis basin under his chin. 4. Separate the client's upper and lower teeth with an oral airway device 5. Cleanse the client's mouth using a toothbrush

A nurse is preparing to administer a medication to a preschooler and must convert the child's weight from pounds to kilograms. The child weighs 30 lb. How many kilograms does the child weigh?

13.6 2.2lb/1kg=Client's weight in lb/xkg 2.2lb/1kg= 30 lb/xkg X=13.636kg

A nurse is preparing to document information about a client's lower legs, which are swollen with 6 mm edema. Which of the following information should the nurse document? 1. 1+ pitting edema 2. 2+ pitting edema 3. 3+ pitting edema 4. 4+ pitting edema

3 + pitting edema

A nurse is reinforcing teaching about carbohydrate counting with a client who has a new diagnosis of diabetes mellitus. Which of the following actions should the nurse take first? 1. Use pictures of different food groups to help client plan a daily menu. 2. Ask the client what he already knows about meal planning. 3. Give the client a brochure with sample menus for all menus. 4. Involve the family in the discussion of the client's meal plan.

Ask the client what he already knows about meal planning.

A nurse is caring for four clients. For which of the following clients should the nurse use the therapeutic communication technique of silence? 1. A client who plans to leave the facility against medical advice 2. A client who informs the nurse that he has made his funeral arrangements 3. A client who tells the nurse that the night shift nurse did not bring his medication 4. A client who has just experienced the death of his child.

A client who has just experienced the death of his child

A nurse is contributing to the plan of care for four clients. For which of the following clients should the nurse initiate airborne precautions? 1. A client who has pneumonia 2. A client who has measles 3. A client who has pertussis 4. A client who has methicillin-resistant Staphylococcus aureas (MRSA)

A client who has measles.

A nurse is documenting client care in a client's electronic health record. Which of the following statements should the nurse include in the documentation? 1. " The client complained about having to get out of bed." 2. "The client was voiding well." 3. "The client became short of breath when ambulating." 4. "The client appears to be comfortable while in bed."

"The client became short of breath when ambulating"

A nurse is reinforcing teaching with the partner of a client who is immobile. Which of the following instructions should the nurse give the partner about turning the client in bed? 1." Keep your feet close together" 2." Tighten your stomach muscles." 3. "Straighten your knees." 4. "Bend at your waist."

"Tighten your stomach muscles"

A nurse is contributing to the plan of care for a client who practices Islam. Which of the following questions should the nurse ask the client to clarify her religious preferences? 1. "Do you receive Holy Communion?" 2. "Do you follow a kosher diet?" 3. " Do you consume pork products?" 4. "Do you oppose receiving a blood transfusion if it is needed?"

"Do you consume pork products?"

A nurse is reinforcing teaching with a client who is scheduled for a bladder scan. Which of the following instructions should the nurse include in the teaching? 1." You will need to sign a consent form before we begin the procedure." 2. "I will place a gel pad directly above your pubic area before I place the probe." 3. " You will need to hold your urine for 1 hour prior to the procedure. 4. "You will receive a contrast dye through an IV catheter prior to the scan.

"I will place a gel pad directly above your pubic area before i place the probe"

A nurse is caring for a client who has dyspnea (difficulty breathing) caused by a respiratory infection. The nurse should assist the client into which of the following positions? 1. Orthopneic 2. Dorsal recumbent 3. Sims' 4. Prone

Orthopneic

A nurse is reinforcing teaching with a client about self-administration of ophthalmic drops. Which of the following instructions should the nurse include? 1. "You will need to look to the side when you put the drops in your eye." 2. "You should put the drops directly in the center of your eyeball." 3. "You should cleanse your eye from the inner to the outer edge prior to putting the drops." 4. " You should avoid pressing on your tear duct after putting the drops in your eye."

You should cleanse your eye from the inner to the outer edge prior to putting in the drops.

A nurse is reinforcing teaching with a client who has pneumonia and a productive cough. Which of the following instructions should the nurse include in the teaching? 1. "Your visitors should wear a protective gown." 2. " You should receive a pneumonia vaccine every year." 3. "You should stand 1 foot away from others when coughing" 4. " You should cover your mouth with a tissue when you cough."

You should cover your mouth with a tissue when you cough

A nurse is collecting data from a client who requires bed rest and reports abdominal discomfort. The nurse notes abdominal distention. Which of the following conditions should the nurse identify as an adverse effect of bed rest? 1. Heartburn 2. Anorexia 3. Constipation 4. Urinary urgency

Constipation

A nurse is providing care to four clients in an acute care setting. The nurse should identify that which of the following client statements presents an ethical dilemma? 1. " I might file a lawsuit because of how my surgery went." 2. "Please don't tell my doctor, but I am taking my partner's oxycodone." 3. " Please don't get me out of bed this morning. It hurts too much." 4. "I don't want to take my medicine. It makes me sick to my stomach."

"Please don't tell my doctor, but i am taking my partner's oxycodone"

A nurse is caring for a group of clients in a long term care facility. Which of the following actions should the nurse take to prevent health care associated infections for these clients? (Select all that apply.) 1. Place immunocompromised clients in the same room. 2. Wash hands after removing gloves. 3. Use antimicrobial hand gel after refilling the client's water pitcher. 4. Clean the stethoscope with an antimicrobial wipe after obtaining vital signs.

*Wash hands after removing gloves *Use antimicrobial hand gel after refilling the client's water pitcher * Clean the stethoscope with an antimicrobial wipe after obtaining vital signs

A nurse manager is reinforcing teaching with a group of newly licensed nurses about the disclosure of client health information. The nurse can disclose health information without the client's written permission to which of the following entities? 1. An insurance agency offering a life insurance policy 2. A family member who request the client's diagnosis 3. A physical therapist who is involved in the client's care 4. An employer completing a pre-employment screening

A physical therapist who is involved in the client's care

A nurse is collecting data from a client who is 2 days postoperative following a colostomy. Which of the following findings should the nurse report to the provider? 1. A purple-colored stoma 2. Protrusion of the stoma 3. A small amount of bleeding from the stoma 4. Intestinal gas in the pouch

A purple-colored stoma

A nurse is caring for a client who is postoperative following a mastectomy. The client states, "I can barely look at myself in the mirror." The nurse should identify that the client is experiencing which of the following? 1. Complicated grief 2. Maturational loss 3. Disenfranchised grief 4. Actual loss

Actual loss

A nurse is caring for a client who has a prescription for a high protein diet to promote wound healing following surgery. The client's religion prohibits eating meat on particular days. Which of the following actions should the nurse take? 1. Encourage the client to eat meat during this time to promote healing. 2. Advise the client to eat everything on the tray except the meat. 3. Suggest the client receive high-protein enteral feedings 4. Ask the dietitian to recommend alternative food choices for the client.

Ask the dietitian to recommend alternative food choices for the client

A nurse is caring for a client who has a new prescription for oxygen at 7 L/min via simple face mask. Which of the following actions should the nurse take to ensure client safety? 1. Keep the side holes of the mask closed. 2. Ensure the reservoir bag is inflated on expiration 3. Apply petroleum jelly to the client's nostrils 4. Attach a humidifier to the base of the flow meter.

Attach a humidifier to the case of the flow meter

A nurse in a long term care facility is collecting admission data from a client who uses a hearing aid. Which of the following actions should the nurse take? 1. Sit beside the client. 2. Speak slowly and loudly to the client. 3. Dim the lights in the client's room. 4. Choose a private room for the interview.

Choose a private room for the interview

A nurse is caring for a client who has an indwelling urinary catheter. Which of the following actions should the nurse take? 1. Clean the perineal area at least one a day 2. Empty the drainage bag when it is three-fourths full 3. Flush the catheter with sterile water daily. 4. Disconnect the drainage bag when emptying and measuring urine

Clean the perineal area at least once a day

A nurse is checking a client for a pulse deficit after detecting an irregular heart rate. Which of the following actions should the nurse take? 1. Count the client's radial and apical pulses simultaneously with another nurse 2. Calculate the client's pulse for 30 seconds and multiply by 2 3. Assist the client to side-lying position 4. Auscultate the area of the client's chest over the Erb's point.

Count the client's radial and apical pulses simultaneously with another nurse

A nurse working in a community clinic is talking with an older adult client who states that his life has no purpose. The nurse should identify that the client is in which of the following stages of Erikson's Theory of Psychosocial Development? 1. Ego integrity vs. despair 2. Generativity vs. self-absorption 3. Identity vs. role confusion 4. Intimacy vs. isolation

Ego integrity vs. despair

A nurse is caring for a client who has chronic pain. The nurse recommends that the client concentrate on a memory of a pleasurable experience. Which of the following complementary therapies is the nurse suggesting? 1. Art therapy 2. Tai Chi 3. Guided imagery 4. Biofeedback

Guided imagery

A nurse is caring for an older adult client and is concerned that the client may have a fecal impaction. Which of the following is the most important question for the nurse to ask? 1. "What types of foods have you been eating?" 2. "Are you using stool softeners or laxatives? 3. "Have you been passing gas?' 4."Have you had small liquid stools?"

Have you had small liquid stools? * this can identify that there is seepage of liquid feces around the impacted mass

A nurse is reinforcing teaching about advance directives with a client who has end-stage renal disease. Which of the following client statements indicates an understanding of the teaching? 1. " I know that I can change my advance directives if I need to in the future." 2. "My health care proxy will make my health care decisions as soon as I have signed the power of attorney." 3. "My family can overrule the decisions made by my health care proxy." 4. "Advance directives from one state are valid in any other state."

I know i can change my advance directives if i need to in the future

A nurse is reinforcing teaching with a client who has hypertension and a prescription to measure her blood pressure daily. Which of the following client statements indicates an understanding of the teaching? 1. "I will wait 15 minutes after drinking coffee to measure my blood pressure." 2." I will measure my blood pressure while my arm is elevated above my heart." 3. " I should remove constrictive clothing prior to measuring my blood pressure." 4. " I should measure my blood pressure immediately after eating breakfast."

I should remove constrictive clothing prior to measuring my blood pressure

A nurse is reinforcing teaching with a client who has insomnia. Which of the following statements by the clients indicates an understanding of the teaching? 1. " I should turn on the ceiling fan to block out unwanted noise." 2. "I will limit my daily nap to 45 minutes." 3. "I will drink a cup of green tea at bedtime to help me sleep. 4." I should get out of bed if i I don't fall asleep within an hour of lying down."

I should turn on the ceiling fan to block out unwanted noise.

A nurse is reinforcing teaching with a new parent of an infant who is concerned about sudden infant death syndrome (SIDS). Which of the following statements by the client indicates an understanding of the teaching? 1. "I will place my baby on her side to sleep." 2. " I should avoid giving my baby a pacifier." 3. "I will remove all stuffed animals from my baby's crib." 4. "I will cover my baby with a light blanket when she is sleeping."

I will remove all stuffed animals from my baby's crib.

A nurse is administering an intramuscular (IM) injection to an adult client. Which of the following actions should the nurse take? 1. Identify the landmarks for the ventrogluteal site before cleaning the skin. 2. Insert the medication after obtaining blood return in the syringe 3. Massage the site after injecting the medication 4. Administer the medication quickly into the injection site

Identify the landmarks for the ventrogluteal site before cleaning the skin

A nurse is caring for a client who has dysphagia(difficulty swallowing) following a stroke. Which of the following interventions should the nurse use when feeding the client? 1. Offer the client a straw to drink liquids. 2. Place food toward the back of the client's mouth. 3. Encourage the client to lie down and rest for 30 min after meals. 4. Instruct the client to tilt her head forward while eating.

Instruct the client to tilt her head forward while eating

A nurse is caring for a client who is scheduled for surgery the following day. During the night, the client is unable to sleep and is restless. Which of the following statements should the nurse make? 1. "It must be difficult facing this type of surgery." 2. "Other clients who have had this surgery have done just fine." 3."This facility is known for providing excellent care for people who need this type of surgery. 4. "I can request a sleeping pill, if you think that will help."

It must be difficult facing this type of surgery.

A nurse is assisting with the care of a client who has a prescription for IV therapy. The client tells the nurse that he has numerous allergies. Which of the following allergies should the nurse bring to the attention of the charge nurse prior to the initiation of the therapy? 1. Eggs 2.Latex 3. Seafood 4. Bee stings

Latex

A nurse is caring for a client who is receiving intermittent enteral feedings. Which of the following is the priority action for the nurse to take? 1. Measure the client's gastric residual before each feeding. 2. Change the bag and tubing every 24 hrs 3. Monitor intake and output. 4. Flush the tubing with 30 mL of water after each feeding.

Measure the client's gastric residual before each feeding

A client who is scheduled to undergo surgery tells the nurse that she does not understand the procedure and is reconsidering her decision to have it. Which of the following actions should the nurse take? 1. Offer information about alternative therapies to the procedure. 2. Contact a family member to convince the client to change her mind. 3. Tell the client the benefits of the surgery. 4. Notify the charge nurse of the client's concerns.

Notify the charge nurse of the client's concerns

A nurse is caring for an older adult client who has advanced rheumatoid arthritis but seldom requests pain medication. Which of the following actions should the nurse take? 1. Question the client using the FACES pain scale. 2. Observe the client for nonverbal indications of pain 3. Wait for the client to report pain before offering medication. 4.Take the client's vital signs to determine if he is experiencing pain.

Observe the client for nonverbal indications of pain

A nurse is assisting with the admission of an adult client to a medical-surgical unit. Which of the following findings should the nurse identify as an indication that the client is malnourished? 1. Heart rate 89/min 2. Pink mucous membranes 3. Pale, scaly skin 4. Body mass index 23

Pale, scaly skin

A nurse is caring for a client who has a new diagnosis of cancer. Which of the following actions should the nurse take to maintain the client's confidentiality while providing care? 1. Share the client's prognosis with a member of the client's family. 2. Discuss the client's status with a member of pastoral care 3. Offer information to a friend of the client over the phone. 4. Provide information to another nurse at change of shift.

Provide information to another nurse at change of shift

A nurse is caring for a client who is at risk for falls. Which of the following actions should the nurse take? 1. Arrange personal items on a table at the foot of the client's bed. 2. Place the back of the bedside commode next to the client's bed 3. Raise four side rails on the client's bed during the night 4. Put the client's bed in the lowest position

Put the client's bed in the lowest position

A nurse in an acute care setting is documenting postmortem care for a client. Which of the following information should the nurse include in the documentation? 1. Completion of an incident report. 2. Name of the nurse certifying the client's death. 3. Release of personal belongings form. 4. Listing of one identifier at the client's time of death.

Release of personal belongings form

A nurse is planning to administer medication to a client who has a Clostridium difficile infection. To prevent the transmission of this infection to others, which of the following actions should the nurse plan to take? 1. Clean hands with an alcohol-based rub immediately after removing gloves. 2. Remove the cover gown in the clients room after providing care. 3. Place the client in a room with negative-pressure airflow 4. Wear a mask when administering oral medications to the client.

Remove the cover gown in the client's room after providing care

A nurse is preparing to remove staples from a client's incision. Which of the following actions should the nurse take? 1. Lift the staple remover when squeezing the handle. 2. Avoid completely closing the handle after squeezing. 3. Expect the staples to bed at each outer side of the staple. 4. Remove the staple from the skin after both sides are visible.

Remove the staple from the skin after both sides are visible

A charge nurse is reinforcing teaching with a newly licensed nurse who is setting up a sterile field. Which of the following actions by the newly licensed nurse indicates an understanding of the teaching? 1. Opening the first flap of a sterile package toward herself 2. Dropping sterile gauze onto the field form a height of 7.5cm (3in) 3.Removing and inverting a lid before placing it onto a nonsterile surface 4. Maintaining the sterile field below waist level.

Removing and inverting a lid before placing it onto a nonsterile surface

A nurse is preparing a client for a Romberg test. Which of the following statements should the nurse make? 1. "Stand with your feet together and your arms at your sides." 2. "After I place the tuning fork, tell me when you no longer hear the sound." 3. "I'm going to stroke the lateral side of the bottom of your foot." 4. " Touch each fingertip as quickly as possible with your thumb.

Stand with your feet together and your arms at your sides.

A nurse is contributing to the plan of care for a client who is at risk for developing foot drop due to immobility. Which of the following actions should the nurse recommend to include in the plan? 1. Flex the client's feet using pillows. 2. Support the client's feet with foot boots. 3. Place a hand roll under the client's heels. 4. Remove ankle-foot orthotic devices at bed time.

Support the client's feet with foot boots

A nurse in a provider's office is providing care for a middle adult client who has minimal exposure to sunlight. Which of the following interventions should the nurse recommend? 1. Reduce intake of calcium-rich foods. 2. Use sunscreen with skin protection factor of 8. 3. Take vitamin D supplements. 4. Use a tanning bed 2 hr weekly.

Take Vitamin D supplements

A nurse working in a hospital overhears the following conversation between two other nurses on the elevator. Which of the following actions should the nurse take?

Tell the nurses that this conversation is not appropriate.

A nurse is collecting data from a client who is 1 day postoperative following abdominal surgery. Which of the following findings is the priority for the nurse to report to the provider? 1. The client reports an incisional pain level of 7 on a scale of 0 to 10. 2. The client reports increased nausea and chill.s 3. The client has an oral temperature of 39 degrees C (102.2 degrees F) 4. The client has redness and warmth in his calf.

The client has redness and warmth in his calf.

A nurse is checking a client's muscle strength. Which of the following techniques should the nurse use? 1. The nurse holds the sides of the client's head and attempts to turn it while the client resists. 2. The client shrugs her shoulders while the nurse applies firm pressure over the midline of the shoulders. 3. The nurse attempts to straighten the client's leg as the client offers resistance while in a seated position. 4. The client holds her arms out and attempts to lower them while the nurse applies upward resistance.

The client shrugs her shoulders while the nurse applies firm pressure over the midline of the shoulders

A nurse is caring for a client who has chronic kidney disease. The nurse should identify that which of the following findings is the priority? 1. Client reports voiding three times during the night. 2. Client reports burning and discomfort with urination 3. The client's WBC count is 11,000/mm3 4. The client's output was 60mL for the past 3 hours

The client's output was 60 mL for the past 3 hr * This represents oliguria and can indicate a decrease in kidney perfusion or function

A nurse is evaluating the crutch-walking technique of a client who is required to keep weight off her right leg. Which of the following is the proper crutch gait for the client? 1. Four-point 2. Three-point 3. Two-point 4. Swing-through

Three-point

A nurse is preparing to obtain a client's vital signs. When washing her hands, which of the following actions should the nurse take? 1. Rinse her forearms with running water before applying soap. 2. Hold her hands above level while washing and rinsing. 3. Generate a lather by rubbing the hands together vigorously for 5 seconds. 4. Turn off the faucet with a clean paper towel after drying hands.

Turn off the faucet with a clean paper towel after drying hands

A nurse is caring for a client who has been vomiting excessively and has diarrhea. Which of the following findings should the nurse identify as an indication of fluid volume deficit? 1. BUN 18mg/dL 2. A bounding pulse 3. Urine specific gravity 1.045 4. Prominent neck veins

Urine specific gravity 1.045 *specific gravity higher than 1.025 indicates that the client's urine is more concentrated, which can be manifestation of fluid volume deficit resulting from dehydration.

A nurse is caring for a client who is receiving chemotherapy and has stomatitis(inflammation of mouth and lips). Which of the following actions should the nurse take to reduce the client's discomfort? 1. Offer the client lemon-glycerin swabs. 2. Encourage the client to drink hot tea 3. Use 0.9% sodium chloride solution to rinse the client's mouth 4. Provide a commercial mouthwash for the clients oral care

Use 0.9% sodium chloride solution to rinse the client's mouth.

A nurse is caring for a client who has limited mobility. Which of the following actions should the nurse take to maintain the client's skin integrity? 1. Use warm water when bathing the client. 2. Place a donut-shaped cushion in the client's chair. 3. Massage reddened areas over bony prominences. 4. Maintain the client in high-fowler's position.

Use warm water when bathing the client.

A nurse is caring for a client who has breast cancer and expresses fear about the future. Which of the following responses should the nurse make? 1. "How long ago were you diagnosed with breast cancer?" 2. " Don't be so frightened. Many people who have breast cancer survive." 3. "You seem really afraid. Let's talk more about your feelings." 4. "Have you talked to your family about your diagnosis? What do they think?"

You seem really afraid. Let's talk more about your feelings