FUNDAMENTALS Part 1
A nurse is caring for a client who has bilateral casts on her hand which of the following actions should the nurse take when assisting the client with feeding?
A nurse should avoid appearing to be in a hurry sitting at the bedside provides the client with the nurses full attention during feeding
A nurse is assessing a client who is experiencing stress and anxiety regarding a recent diagnosis. Which of the following findings should the nurse expect?
A nurse should expect a client who is experiencing stress and anxiety to manifest an increase in blood pressure and heart rate as a result of the sympathetic stimulation
A nurse is planning to assess the AB dominant of a client who reports feeling bloated for several weeks which of the following methods of assessment should the nurse use first?
According to evidence based practice the nurse should inspect the abdominal first by observing the contour of the abdominal the condition of the skin and the position of the umbilicus findings from this step of assessment are used by the nurse in the subsequent steps
A nurse is teaching a group of young adults. Which of the following should the nurse identify as an expected developmental task for this age group?
According to kohlberg's theory of moral development, making individual decisions about moral issues is a function of the highest level of moral development, the postconventional level. Young adults who have reached this level separate themselves from the from the rules and tenants of others and make their own decisions according to personal belief in principle.
A nurse is measuring the blood pressure of several clients which of the following results is within the expected reference range for blood pressure?
Anything less than 120 / 80 is expected reference range
A nurse in urgent care centers caring for a 15 year old client who symptoms suggest a sexually transmitted infection STI. The client's parents are and unavailable but the clients grandmother accompanied the client to the clinic which of the following actions should the nurse take?
Ask the adolescent to sign the consent form. UN emancipated minors those who do not live on their own are not married and are not in the military can leave legally give informed consent for diagnostic procedures and treatments in some situations. These situations include treatment for STI's and substance use disorders
A charge nurse is providing teaching to a newly licensed nurse about removing sutures from a client's lacerations which of the following statements by the newly licensed nurse indicates an understanding of the teaching?
Clipping close to the skin and pulling the suture from the other side does not disrupt wound healing process
A nurse is planning care for a client who has a prescription for collection of sputum specimen for culture and sensitivity. Which of the following actions should the nurse take when obtaining the specimen?
Collect the specimen when the client rises in the morning. The nurse should plan to collect the sputum specimen when the client arises in the morning because the client will be able to cough up the secretions that have accumulated during the night. Generally the deepest specimens are obtained in the early morning and it is preferable to collect the specimens before breakfast. The nurse should instruct the client to rinse the mouth take a deep breath and cough prior to expectorating into the sterile container
A nurse is working with the facilities language interpreter to explain a wound care procedure to a client who does not speak the same language as the nurse. Which of the following actions should the nurse take when describing the procedure to the client?
Ensure the interpreter and the client speak the same dialect to encourage effective communication and promote client understanding the nurse should first ensure the interpreter and the clients speak the same dialect
A nurse is changing the dressings for a client who is 3 days post operative following a Kohli cystectomy the nurse observes yellow thick drainage on the dressing the nurse should document this finding as which of the following types of drainage?
Purulent exudate on the clients dressing includes thick yellow green or brown drainage and usually indicates wound sloughing or infection
A nurse is assessing a client's vascular system which of the following techniques should the nurse use when evaluating the carotid arteries?
The bell of the stethoscope is more effective than the diaphragm in transmitting blowing or swishing sounds such as those from turbulence in blood vessels
A nurse is called away from an emergency while conversing with a client who is concerned about his medical diagnosis the nurse returns to the client promptly as promised which of the following ethical principles is the nurse demonstrating ?
The nurse is demonstrating the ethical principle of fidelity by keeping a promise that was made
A nurse is providing teaching to a client with heart failure about reducing his daily intake of sodium. Which of the following factors is the most important in determining the client's ability to learn new dietary habits?
The involvement of the client in planning the change according to evidence based practice client involvement in planning dietary changes is the most important factor in the client's ability to learn new habits
A nurse is inserting an Ng tube into a client who begins to cough and gag which of the following actions should the nurse take?
The nurse had slightly pulled back the Ng tube and instructed client to breathe slowly once the client relaxes the nurse should gently advance the tube as a client swallows
A nurse is caring for a postoperative client who has an indwelling urinary catheter for gravity drainage the nurse notes no urine output in the past two hours which of the following actions should the nurse take first?
The nurse should apply the least invasive priority setting framework when caring for this client which assigns priority to nursing interventions that are least invasive to the client as long as the interventions do not jeopardize the client safety this approach reduces the number of organisms introduced into the body decreasing the number of facility acquired infections hence the first action the nurse should take is to inspect the tubing carefully straighten any kinks and ensure that there are no dependent loops a lack of drainage is often due to a kink in the tubing or the clients lying on it.
A nurse is caring for a client who has Clostridium dificil infection and is in contact isolation. Which of the following actions should the nurse take?
Wear gloves when changing the client's gown the nurse should wear gloves when handling articles that have the potential to contaminate the hands when caring for a client in contact isolation
A nurse is teaching a client about how to remove a soiled dressing which of the following statements by the client indicates an understanding of the teaching?
Wearing gloves prevents the spread of microorganisms outside of the dressing and onto the clients hands the gloves the client uses can be clean and do not need to be sterile unless the provider specifically prescribed sterile gloves for dressing changes
A newly licensed nurse is preparing to administer medications to a client. The nurse notes that the provider has prescribed a medication that is unfamiliar to him. Which of the following actions should the nurse take ?
a nurse must have knowledge about medications to administer them safely. The nurse should become familiar with the medications by looking it up in the medication reference on the unit.
A nurse is caring for a client who has a terminal illness which of the following findings indicates that the client's death is in imminent?
The presence of cold extremities first in the feet and then in the hands is a physical change that occurs when clyne's death is imminent
A nurse is preparing to administer an intramuscular injection to a young adult client. Which of the following injection sites is the safest for this client?
Ventrogluteal according to evidence based practice the ventral gluteal site is the safest injection site for all adults because it contains thick gluteal muscles and does not contain major nerves or blood vessels.
As the nurse is preparing to administer liquid medication from a bottle to a client which of the following actions should the nurse take?
hold the medication bottle with the label against the palm of the hand when pouring the nurse should hold a multi dose bottle with the label against the palm and had when pouring to prevent contaminating the label and spilling the medication that could cause information on the label to fade or become illegible
A nurse is caring for a client who is exhibiting confusion. The nurse should identify that which of the following laboratory values can cause confusion? Sodium 123, glucose, 100, potassium 3.5, hemoglobin 13
A sodium level of 123 is below the expected reference range of 136 to 145. Low sodium levels can cause confusion and lead to seizures coma and death
A nurse is performing sectional suctioning for a client who has a tracheostaomy which of the following actions should the nurse take?
The nurse should pull the suction catheter back 1 centimeter when the client starts to cough or resistance is met this will remove the catheter from the mucosal wall of the trachea prior to suctioning
A nurse is assessing a client's respiratory system. Which of the following breath sounds should the nurse expect to hear over periphery of the major lung fields?
The nurse will hear vesicular sounds over the periphery of the major longfields these sounds are soft and low pitched
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. To sue the client's throat following a tonsillectomy the nurse should administer pain medication routinely the nurse can provide the medication rectally and or intravenously to avoid the oral route
A nurse is providing preoperative teaching to a client who is scheduled for arthroplasty in the next month and may require a blood transfusion. The client expresses concern about the risk of acquiring an infection from the blood transfusion. Which of the following statements should the nurse share with the client?
Autologous blood transfusion is a collection of re infusion of the client's blood with preoperative autologous blood donation the blood is drawn from the client three to five weeks prior and elective surgical procedure and stored for transfusion at the time of surgery autologous blood is the safest form of blood transfusion because exclusive use of clients own blood eliminates exposure to a transfusion transmitted infection
A nurse on a medical unit is caring for a client who has difficulty sleeping which of the following actions should the nurse take to promote the client's ability to fall asleep?
For many clients in an acute care facility disrupting the usual sleep routine is the primary reason for our clients inability to sleep maintaining the home bedtime routine promotes sleep in ways that are effective for the client those who usual bedtime routines include warm milk massages or pharmacological sleep aids might need and appreciate those interventions in inpatient settings
A nurse is administering a cleansing anema to a client who is scheduled for a diagnostic procedure. Which of the following actions should the nurse take?
Insert the tip of the tubing 8 centimeters 3.1 inches the nurse should insert the tip of the tubing 7 to 10 centimeters three to four inches along the rectal wall to prevent dislodging of the tube during the procedure and avoid injury to the rectal mucosa
A nurse is performing an admission assessment for a client who has asthma and reports several food allergies which of the following actions should the nurse take first?
The nurse should apply the nursing process priority setting framework in order to plan client care and prioritized nurse actions each step of the nursing process builds on the previous step beginning with the assessment or data collection before the nurse can formulate a plan of action implement a nursing intervention or notify the provider of a change in the client status the nurse must first collect adequate data from the client assessing or collecting additional data will provide the nurse with the knowledge to take appropriate decisions therefore the nurse should first assess the client's allergies and identify the specific allergies to ensure the specific foods are not offered to the client during meals
A nurse is caring for a client who requires a peripheral Ivy insertion. When choosing the site which of the following sites should the nurse select ?
the nurse should select a vein that is soft and has a bouncy feeling when pressure is released upon palpation
A nurse is teaching a client how to perform range of motion exercises of the wrist period to perform adduction , which of the following instructions should the nurse include ?
with your palm facing down, move your wrist sideways toward your thumb. This motion describes adducting the wrist the client should be able to move her wrist 30 degrees to 50 degrees with this motion.
A nurse is monitoring a client's laboratory results. Which of the following results should the nurse report to the provider? Sodium 140, potassium 3.0, chloride 100, Magnesium 2.0
the potassium level is 3 point oh which is below the expected Reference range of 3.6 to 5.2 Indicating hypokalemia. The nurse should report this finding to the provider for instructions about preventing muscle weakness that could affect respiration.
a nurse is teaching range of motion exercises to a client who has osteoarthritis which of the following client positions demonstrate understanding of supination of the hand ?
The nurse should identify the client holding the hand with the palm up as a demonstration of supination of the hand
A nurse is teaching a client who is recovering from gallbladder surgery how to use an incentive spirometer. Which of the following pieces of information should the nurse include in the teaching?
The nurse should instruct the client to hold their breath for three to five seconds after reaching maximal inspiration volume this decreases the collapse of alveolae which helps prevent the risk of atelectasis and pneumonia
