Fundamentals I
A nurse is collecting date for the health history of a client who is postoperative and has paralytic ileus. Which of the following should the nurse expect?
Absent bowel sounds with distention
A nurse is caring for a child who is postoperative following a tonsillectomy. Which of the following actions should the nurse take?
Administer analgesics to the child on a routine schedule throughout the day and night
A nurse is planning weight loss strategies for a group of clients who are obese. Which of the following actions by the nurse will improve the clients commitment to a long-term goal of weight loss.
Attempt to increase the clients self-motivation
A nurse is drawing blood for laboratory testing from a client that results in a blood spill on her gloved hand. The client has no documented bloodstream infection. Which of the following action should the nurse take?
Carefully remove the glove and follow with hand hygiene
A nurse is reviewing adult cardiopulmonary resuscitation with a newly licensed nurse. Which of the following steps should the nurse identify as the first response when performing CPR?
Confirm unresponsiveness
A nurse is measuring vital signs for a client and notices an irregularity in the pulse. Which of the following actions should the nurse take?
Count the apical pulse rate for 1 full minute, and describe the rhythm in the chart.
A nurse on a medical surgical unit is admitting a client. Which of the following information should the nurse document in the clients record first?
Data collection for the client
A nurse is reinforcing preoperative teaching with a client who is scheduled for arthroplasty in the next month and might require blood transfusion. The client expresses concern about the risk of acquiring an infection from the blood transfusion. Which of the following suggestions should the nurse make?
Donate autologous blood before the surgery
A nurse is caring for a client who has a terminal illness. The client asks several questions about the nurses religious beliefs related to death and dying. Which of the following actions should the nurse take?
Encourage the client to express his thoughts about death and dying.
A nurse is collecting date for a client who has decreased circulation in his left leg. Which of the following actions should the nurse take first.
Evaluate pedal pulse
A nurse is collecting data for a client who has had diarrhea and decreased urination for several days. Which of the following actions should the nurse take to determine if the client is dehydrated?
Grasp a skin fold on the chest under the clavicle, release it, and note whether it springs back
A nurse in an oncology clinic is collecting date for a client who is undergoing treatment for ovarian cancer. Which of the following statements by the client indicates she is experiencing phychological distress?
I keep having nightmares about my upcoming surgery
A nurse is reinforcing teaching with a group of older adults about expected changes of aging. Which of the following statements by a group member indicates that the teaching has been effective?
I should expect my heart rate to take longer to return to normal after exercise as I get older
A nurse is caring for a client who requires a chest x-ray. Prior to the client being transported for the procedure, which of the following actions should the nurse take first?
Identify the client using two identifiers
A nurse is collecting date for an older client. Identify the correct sequence of steps used for data collection of the abdomen.
Inspect auscultate percussion palpate
A nurse is receiving a client from the PACU who is post operative following abdominal surgery. Which of the following actions should the nurse take to transfer the client from the stretcher to the bed?
Lock the wheels on the bed and stretcher
A nurse is preparing a client who is scheduled for a hysterectomy for transport to the operating room when the client states she no longer wants to have the surgery. Which of the following actions should the nurse take?
Notify the provider about the clients decision
A nurse on a medical-surgical unit is caring for a client. Which of the following actions should the nurse take first when using the nursing process.
Obtain client information
A charge nurse is observing a newly licensed nurse perform tracheostomy care for a client. Which of the following actions by the newly licensed nurse requires intervention?
Obtaining cotton balls for the tracheostomy care
A nurse is preparing to provide tracheostomy care for a client. Which of the following should the nurse take first?
Perform hand hygiene
A nurse is auscultating the heart sounds of a client who has developed chest pain that worsens with inspiration. The nurse hears a high-pitches scratching sound with the diaphragm of the stethoscope placed at the third intercostal space of the left sternal border. Which of the following heart sounds should the nurse document?
Pericardial friction rub
A nurse is obtaining the blood pressure in a clients lower extremity. Which of the following actions should the nurse take?
Place the bladder of the cuff over the posterior aspect of the thigh
A nurse on a rehabilitation unit is preparing to transfer a client who is unable to walk from a bed to a wheelchair. Which of the following techniques should the nurse use?
Place the wheelchair at a 45 degree angle
A nurse is preparing to perform oral care for a client who is unresponsive. Which of the following actions should the nurse plan to take?
Raise the level of the bed
A nurse is caring for an older adult who is violent and attempting to disconnect her IV lines. The provider prescribes soft wrist restraints. Which of the following actions should the nurse take while the client is in restraints.
Remove the restraints one at a time
A nurse is assisting with planning a community campaign about seasonal influenza. Which of the following plans should be included as a secondary prevention strategy?
Screening groups of older adults in nursing care facilities for early influenza manifestations
A nurse at a screening clinic is collecting data for a client who reports a history of a heart murmur related to aortic valve stenosis. At which of the following anatomical areas should the nurse place the stethoscope to auscultate the aortic valve.
Second intercostal space to the right of the sternum
A nurse is caring for a client who is in the terminal stage of cancer. Which of the following actions should the nurse take when she observes the client crying?
Sit and hold the clients hand
A nurse is reinforcing teaching with an older adult client who has constipation. Which of the following statements should the nurse include in the teaching.
Sit on the toilet 30 min after eating a meal
A nurse is caring for a client who has Type I Diabetes Mellitus and is resistant to learning self-injection of insulin. Which of the following statements should the nurse make?
Tell me what I can do to help you overcome your fear of giving yourself injections
A nurse is collecting date from a client who reports abdominal pain. Further finding reveal the client has a temperature of 39.2 (102.6), a heart rate of 105/min, a soft nontender abdomen, and menses overdue by 2 days. Which of the following finding should be the nurses priority?
Temperatue
A nurse is planning to obtain the vital sign of a 2-year-old who is experiencing diarrhea and who may have a right ear infection. Which of the following routes should the nurse use to obtain the temperature.
Temporal
A nurse is reinforcing teaching of postoperative deep breathing and coughing exercises with a client who will have emergency surgery for appendicitis. Which of the following statements indicates a lack of readiness to learn by the client?
The client reports severe pain
A nurse is reinforcing teaching with a client who has heart failure about how to reduce his daily intake of sodium. Which of the following factors is the most important in determining the clients ability to learn new habits?
The involvement of the client in planning the change
A nurse on a medical-surgical unit is washing her hands prior to assisting with a surgical procedure. Which of the following actions by the nurse demonstrates proper surgical hand-washing technique?
The nurse washes with her hands held higher than her elbows
A nurse is witnessing a client signing an informed consent form for surgery. Which of the following describes what the nurse is affirming by the action?
The signature on the preoperative consent form is the clients
A nurse is instructing an assistive personnel (AP) about proper hand hygiene. Which of the following statements by the AP indicates an understanding of the teaching?
There are times I should use soap and water rather than an alcohol-based hand rub to clean my hand.
A nurse observes an assistive personnel preparing to obtain blood pressure with a regular size cuff for a client who is obese. Which of the following explanations should the nurse give the AP?
Using a cuff that is too small will result in an inaccurately high reading
A nurse is caring for an older adult client who becomes agitated when the nurse requests that the clients dentures be removed prior to surgery. Which of the following responses should the nurse make?
What worries you about being without your teeth
A nurse is caring for a client who is unstable and has vital signs measured every 15 minutes by an electronic blood pressure machine. The nurse notices the machine begins to measure the blood pressure at varied intervals and the reading are inconsistent. Which of the following actions should the nurse take?
Disconnect the machine and measure the blood pressure manually every 15 min