Fundamentals pg. (17-50) 60 questions

A nurse is caring for a client whose intake and output flow sheet for 0700 to 1500 indicates the following: voided x3:350 mL, 200mL, 150 mL; wound drainage 2 tsp; and emesis 2 oz. What is the total output in mL with the nurse should document for his 8-hour period?

1 tsp= 5mL 1 0z= 30mL Answer= 770mL

A nurse is collecting data for the health history of a client who is postoperative and has paralytic ileus. Which of the following findings should the nurse expect?

Absent bowel sounds with distention

A nurse is admitting a client who has MEASLES. Which of the following types of transmission precautions should the nurse initiate?

Airborne Airborne: - varicella - tuberculosis (TB) - measles Droplet: - rubella - meningococcal pneumonia - streptococcus pharyngitis Contact: - vancomycin-resistant enterococci - methicillin-resistant aureus - scabies

A nurse is caring for a client who has a terminal illness. The client is restless and reports severe pain and refuses the prescribed opioid pain medication. Which of the following actions should the nurse take first?

Ask why the client is refusing the pain medication

A nurse is collecting baseline data of a client's peripheral vascular system. In which of the following locations should the nurse palpate the posterior tibial pulse?

Below the medial malleolus

A nurse is assisting with teaching a newly licensed nurse about pain management in clients age 65 and older. Which of the following pieces of information should the nurse include?

Clients who are age 65 or older are reluctant to report pain

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 skinfold on the chest under the clavicle, release it, and note whether it springs back

A nurse is assisting with the planning of an in-service training session about various dietary practices. Which of the following pieces of information should the nurse recommend including in the teaching?

Kosher diets involve restrictions regarding how food must be prepared - (Ovo-vegetarian diet): primary vegetables except EGGS - (Macrobiotic diets): primarily PLANT-BASED but do include fish and seafood - (Flexitarian diets): primarily plant-based with occasional consumptions of meat, fish, and dairy products.

A nurse on a medical-surgical unit is caring for a client who develops deep, rapid respirations. Arterial blood gas analysis includes the following values: pH 7.25, PaCO2 40, and HCO3-18. Which of the following acid-base imbalances should the nurse identify and report to the provider?

Metabolic acidosis

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 (can be aspirated into tube opening; possibly causing tracheal abscess) Understanding (no intervention needed): - half-strength peroxide solution is used to clean the inner cannula - tracheostomy care is a sterile procedure requiring the use of sterile gloves - Pipe cleaners or small brush can be used to remove thick or crusty secretions from the inner cannula

A nurse employs a thorough, systemic method for obtaining objective data about a client. Which of the following methods should the nurse use to collect this information?

Physical examination Objective data: physical data we can observe using our senses Subjective data: information from the client's point of view ("symptoms"), including feelings, perceptions, and concerns obtained through interviews.

A nurse on a rehabilitation unit is preparing to transfer a client who is unstable 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 to the bed (allows the client to pivot, lessening the amount of rotation required) - stand in front of the client toward to side that requires the MOST support. This technique will help maintain balance during the transfer. - safely transferring a client from a bed to a wheelchair requires the nurse to INSTRUCT the client to lean forward from the hips. -Safely transferring a client from a bed to a wheelchair requires the nurse to assume a wide stance with a foot in front of the other

A nurse is caring for a client who is receiving intermittent eternal feedings though an NG tube. The specific gravity of the client's urine is 1.035. Which of the following actions should the nurse take?

Provide more water with feedings Normal URINE SPECIFIC: 1.005-1.030 (elevation in client specific gravity indicates= dehydration) adding water to feeding or instilling water between feedings **Another strategy is to request a formula that contains less protein**

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?

Pull the NG tube quickly