Fundamentals Practice

A nurse is reinforcing teaching with a client about using transdermal patches at home. Which of the following statements should the nurse identify as an indication that the client understands the teaching? - "will remove the old patch and apply a new one in the same location - will press the patch securely in place on my forearm. - "will clean and dry the area before applying the patch - will use lotion on irritated skin before applying a new patch in that area

- "will clean and dry the area before applying the patch

A nurse is caring for a client who has hypernatremia and requires IV fluid therapy due to his NPO status. Which of the following solutions should the nurse prepare to infuse for this client? - LRs - Dextrose 5% in 0.9% NaCl - 0.45% NaCl - Dextrose 10% in water

- 0.45% NaCl

A nurse is caring for a client who has an indwelling urinary catheter and notes blood - tinged urine in the catheter bag . The nurse recognizes this finding can be a manifestation of which of the following urinary alterations ? - Pernicious anemia - Dehydration - Prostate enlargement - Bladder infection

- Bladder infection

A nurse who is left - handed is preparing to perform a straight catheterization for a client . Which of the following actions should the nurse take ? - Raise the side rail on the working side of the bed - Use the non - dominant hand to insert the catheter - Stand on the left side of the bed - Raise the bed to a comfortable height

- Raise the bed to a comfortable height

A nurse is caring for a client who needs a stool specimen collected . Which of the following actions should the nurse take when obtaining the specimen ? - Use a sterile swab to obtain the specimen . - Place the specimen in a sterile container . - Label the paper bag in which specimen container is placed - Send specimen container immediately to the lab .

- Send specimen container immediately to the lab .

A nurse is caring for a client who experienced a lacerated spleen and has been on bedrest for several days . The nurse auscultates decreased breath sounds in the lower lobes of both lungs . The nurse should realize that this finding is most likely an indication of which of the following ? - upper respiratory infection - pulmonary edema - atelectasis - delayed gastric emptying

- atelectasis

A nurse is assigned to care for four clients who have drainage tubes. Which of the following clients should the nurse recognize is at risk for hypokalemia? - has tach tube attached to humidified oxygen -has an indwelling urinary cath to gravity drainage - has chest tube to water seal - client who has an NG tube to suction

- client who has an NG tube to suction

A nurse on a medical unit is caring for a client who suddenly becomes confused and drowsy. Additional data include pulse 100/min, RR 24/min, BP 132/76 mmHg, and temp 36.8C (98.2F). Which of the following actions should the nurse perform? - neurological check - admin the prescribed PRN antihypertensive med - increase the client's fluid intake - hold the client's evening dose of digoxin

- neurological check

A nurse is caring for an older adult client who is at risk for skin breakdown. Which of the following interventions should the nurse use to help maintain the integrity fo the client's skin? - reposition every 3 hr - massage bony prominence to promote circulation - provide the client with a diet high in protein - apply cornstarch to keep the skin dry

- provide the client with a diet high in protein

a nurse is assessing a client who is experiencing prostatic hypertrophy. which of the following findings associated with urinary retention should the nurse expect? (select all that apply) - report of feeling pressure - tenderness over the symphysis pubis - distended bladder - voiding 30 mL freq - dysuria

- report of feeling pressure - tenderness over the symphysis pubis - distended bladder - voiding 30 mL freq

A nurse is assessing a client and discovers the infusion pump with the client's TPN solution is not infusing. The nurse should monitor the client for which of the following conditions? - excessive thirst and urination - shakiness and diaphoresis - fever and chills - hypertension and crackles

- shakiness and diaphoresis (hypoglycemia)

A nurse is teaching an AP about using PPE while caring for clients. Which of the following statements should the nurse id as an indication that the AP understands the instructions? - wear gloves whenever i am in contact w/ clients - wear gloves and gown when bathing a client who has open skin lesions -wear gloves to minimize the number of times i have to wash my hands - wear gloves when measuring a client's blood pressure

- wear gloves and gown when bathing a client who has open skin lesions

A nurse is caring for a client who is scheduled for an elective surgical procedure. which of the following actions should the nurse take regarding informed consent? - obtain the client's consent - witness the signature -explain the risks and benefits of the procedure - explain the procedure to the client if they don't understand

- witness the signature

A nurse enters an older adult client's room to insert a saline lock. the client asks the nurse, "Why do i need that? I am drinking plenty of fluids." Which of the following responses should the nurse provide/ - it's quicker to admin meds IV in the hospital - clients over the age of 65 must have a saline lock according to facility policy - we administer all meds IV to clients in this unit - your provider has prescribed antibiotic therapy to be administered IV every 6 hr

- your provider has prescribed antibiotic therapy to be administered IV every 6 hr

A charge nurse is making client care assignments. Which of the following tasks should the nurse plan to delegate to assistive personnel (AP)? (SATA) -Bathing a client who had an amputation 2 days ago. - Assisting a client to ambulate using a gait belt. -Review a low-sodium diet for a client who has HTN - explain oral hygiene to a client receiving chemo -Feeding a client who had a stroke 3 months ago.

-Bathing a client who had an amputation 2 days ago. - Assisting a client to ambulate using a gait belt. -Feeding a client who had a stroke 3 months ago.

a charge nurse is reviewing guidelines for initiating airborne precautions. which of the following clients should the nurse id as requiring airborne precautions? -scabies -pertussis -streptococcal pharyngitis -measles

-measles

A nurse is receiving a provider's prescription for a client via telephone. Which of the following actions should the nurse take to ensure the accuracy of the telephone prescription? (Select all that apply) -Repeat the order back to the provider -Question any part of the order that is unclear or inappropriate -Transcribe the order into the client's health record -obtain the provider's signature w/i 8 hr -implement a recorded order message if the nurse can hear and understand it clearly

-Repeat the order back to the provider -Question any part of the order that is unclear or inappropriate -Transcribe the order into the client's health record

a nurse is preparing to admin soapsuds enema to an adult client. which of the following actions should the nurse take? - put on sterile gloves -assist the client to left sim's position - hang the enema container 60 cm (24 in ) above the anus - inser the tubing about 15 cm (6in) into the anus

-assist the client to left sim's position

a nurse is caring for a client who is post-op and has a prescription for anti embolic stockings. which of the following actions should the nurse take? -apply the stockings while the client is sitting in a chair. -remove the stockings once each day -check the stocking for wrinkles -measure the size of the client's foot

-check the stocking for wrinkles

a nurse is preparing to admin a cleansing enema to a client. which of the following actions should the nurse take? -keep the container of solution at level to maintain client comfort -hold the container of solution 30 cm (12in) above the anus -hold the container of solution level with the client's upper hip - hold the container of solution 15 cm (6in) above the nausea, then lower it 15 cm below the anus

-hold the container of solution 30 cm (12in) above the anus

A nurse is preparing a for outpatient surgery. After the nurse inserts the catheter, the client reports pain the Insertion area. Which of the following actions should the nurse take? -remove the catheter and insert another into a different site - Administer an analgesic - Request a prescription for placement of a central venous access device -Administer a local anesthetic

-remove the catheter and insert another into a different site

a nurse is caring for a client who is at risk for falls. which of the following actions should the nurse take? (select all that apply) -keep the client's room dark at night -teach the client to use the call light -keep the client's bed in the lowest position -place a fall-id band on the client's wrist -assess the client every 4 hr

-teach the client to use the call light -keep the client's bed in the lowest position -place a fall-id band on the client's wrist

a nurse is administering nasal decongestant drops for a client. Which of the following actions should the nurse take? -tell the client to blower her nose gently before the instillation -assist the client to a side-lying position -hold the dropper 2 cm (1in) above the naris -instruct the client to stay in the same position for 2 min

-tell the client to blower her nose gently before the instillation

A nurse is caring for a client and observes that the client's is dark amber, , and has unpleasant The nurse should recognize that these findings are associated with which of the following? -urinary tract infection -urinary incontinence - urinary frequency -Urinary retention

-urinary tract infection

A nurse is admitting a client who has pertussis. Which of the following types of transmission based precautions should the nurse take?

Droplet

trach suctioning

adjust suction, sterile gloves, check fxn, hyper oxygenate, insert, apply suction and rotate cath, assess for clearance of secretions

a nurse is assessing for cyanosis in a client who has dark skin. Which of the following sites should the nurse examine to id cyanosis in this client?

conjunctivae