Fundamental's Practice Questions
A patient discusses unhealthy family relationships with the nurse. During the nurse-client interaction, the client starts talking about job problems. The nurse's response is "lets go back to what were just talking about." which communication technique did the nurse use
Focusing
a patient is in need of immediate pain relief for a severe headache. the nurse knows that which medication will be absorbed the quickest?
Hydromorphone (Dilaudid) 4 mg IV
A nurse is assessing several clients. Which client will require parenteral nutrition?
a client with severe malabsorption disorder
When caring for a client who is receiving enteral feedings, the nurse should take which measure to prevent aspiration
elevate the head of the bed between 30 to 45 degrees
To ensure the safety of a client who is receiving a continuous intravenous normal saline infusion, the nurse should change the administration set every
every 72-96 hours
A client who is dying jokes about the situation even though the client is becoming sicker and weaker. Which is the most therapeutic response by the nurse?
"Does it help to joke about your illness?"
After being medicated for anxiety, a client says to a nurse, "I guess you are too busy to stay with me." How should the nurse respond?
"I have to go now, but I will come back in 10 minutes."
the nurse is teaching a client about safe insulin administration. Which statment made by the client indicates the need for further education?
"I should administer insulin only if there are symptoms"
A client has an order for a sublingual nitroglycerin tablet. the nurse should teach the client to use what technique when self-administering this medication?
place he pill under the tongue and let it dissolve
A nurse assists a client who had bariatric surgery to be more mobile. What complication is the nurse attempting to prevent?
pulmonary embolism
the healthcare provider prescribes Lovenox (anticoagulant) to be administered subcutaneously daily to a client who had a total knee replacement. to ensure client safety, which measure would the nurse take when administering this medication?
administer in abdomen area
A registered nurse is evaluation the statements of a new orienting nurse about wound dressing. Which statement made by the new orienting nurse indicates further teaching is needed?
"I should take the cotton swab placed on the table"
A nurse is administering an intradermal injection. at which angle should the nurse insert the needle?
15 degree angle
A registered nurse is educating a nursing student about the importance of nursing documentation for performing risk management. What information should the nurse give?
A nurse's documentation is the evidence of care that a client receives The nurse should note down assessments and significant changes in the client's health Nurses should always document the primary healthcare provider's responses whenever they are contacted
A client requests information about the prescribed medication regimen. What is the best response by the nurse?
Ask the client to state what is already known about the medication
A 2 gram sodium diet is prescribed for a patient with stage 2 hypertension. the client reports distaste for the food. the nurse hears the patient tell his family to bring him a ham and cheese sandwich with fries. What is the most effective nursing intervention?
Discuss the diet with the client and family
When reviewing a drug to be administered, the nurse identifies that the package insert indicates that the Z-track injection technique should be used. Under which circumstance does the nurse expect that this technique will be necessary?
Medication is irritating to subcutaneous tissue and skin
A nurse uses therapeutic communication techniques in order to achieve desired client outcomes. Which communication technique is a part of therapeutic communication?
Providing relevant information to the client
A nurse is taking care of a client who has chronic back pain. What nursing considerations should be made when determining the client's plan of care?
ask the client about the acceptable level of pain, administer the pain meds regularly around the clock
To prevent excessive bruising when administering subcutaneous heparin, what technique will the nurse employ?
avoid messaging the injection site after the injection
A nurse places a client with severe burns on a circulating air bed. Which goal is the nurse trying to achieve?
preventing pressure on peripheral blood vessels
The nurse is caring for a client with deep partial- thickness burns who is receiving opioid for pain management. What is the preferred mode of medication administration for this client
intravenous
a home-care nurse observes the spouse of a patient inserting a rectal suppository. what behavior indicates that the nurse must provide further teaching about suppository administration?
inserts the suppository while the patient bears down
the client's spouse, slips and falls on a recently washed floor. to meet the criteria of ethical practice, what action should the nurse who witnessed the occurrence take?
initiate an agency incident report
A nurse is providing education about excellent food sources of vitamin A for a client who is deficient in this vitamin. Which foods should the nurse include in the teachings?
carrots, green leafy veggies, yellow/orange veggies
A nurse is preparing to administer an ophthalmic medication to a client. What techniques should the nurse use for this procedure?
clean the eyelid and eyelashes apply clean gloves before beginning the procedure press on the nasolacrimal duct after instilling the solution
The nurse receives a report on a newly admitted client who is positive for Clostridium difficle. Which category of isolation would the nurse implement for this client
contact precaution
A nurse is caring for a client who has developed dysphagia and is unable to swallow. the client is receiving around the clock opioid pain meds for cancer pain, and hospice has recently begun caring for the client. what is the best nursing intervention in preparing for the client's discharge
contact the client's healthcare provider to discuss use of transdermal meds for pain control
The nurse is preparing discharge instructions for a patient with early signs of Alzheimer dementia. The client lives alone. the client's adult children live nearby. according to the prescribed medication regimen, the client is to take meds six times throughout the day. what is the priority nursing intervention to assist the client taking the meds
contact the primary health care provider and discuss the possibility of simplifying the medication regimen
A primary nurse receives prescriptions for a newly admitted client and has difficulty reading the healthcare provider's writing. who should the nurse ask for clarification of this prescription?
healthcare provider who wrote the prescription
the registered nurse is teaching a nursing student about the safety guidelines for nursing skills. Which statement by the student nurse nurse indicates the need for further education?
"I should advise the certified medical assistant to administer intravenous medication"
A nurse is teaching about near- miss events to a group of nursing students. What's appropriate for the nurse to include in the education?
they do not cause actual harm to the patient they are caused by a variation in standard care their cause can be analyzed by failure mode effective analysis
An isolated older adult is diagnosed with cancer and fears death. Which intervention provided would help to induce relaxation and to communicate interest in the client?
touch
the client receiving an intravenous infusion of morphine sulfate begins to experience respiratory depression and decreased urine output. this effect is described
toxic
A geriatric patient with hypertension and diabetes mellitus is taking propranolol (inderal) and insulin (Humulin N) therapy. Which interventions by health care professionals help prevent patient medication errors according to the Leapfrog group?
using computer physician order entry
After three months of supplemental oral iron therapy, there is no significant increase in an adolescent's hemoglobin level. Iron dextran is prescribed. What is the best way for the nurse to administer this medication?
with the use of the Z-track method
A nurse is administering an intradermal skin test injection to a client. What is the next action the nurse needs to do after the medication has been injected?
withdraw the needle and place a piece gauze over the injection site
the registered nurse is teaching a nursing student about the process of medication reconciliation for a client who was admitted in a healthcare setting. which statement made by the nursing student indicates a need for further education
I should avoid asking about the over-the counter medications
what is the most important nursing action invilved in caring for a client using medications to manage disease
administering the medications
A nurse is reviewing a newly admitted client's medication administration record. Which element, if missing, makes the record incomplete?
allergies
The nurse is preparing to administer ear drops to a client who has impacted cerumen. Before administering the drops, the nurse will assess the client for which contraindications?
allergy to medication, drainage from ear canal, tympanic membrane rupture
A client is placed on a restricted diet. What is the best communication technique for the nurse to use when beginning to teach the client about the diet
asking about what the client knows about the diet that was prescribed
A 15 year old is admitted with partial and full thickness burns of the arms and upper torso. What are the purposes of administering pain meds by way of the intravenous route rather than the intramuscular route?
it decreases the risk of tissue irritation, severe pain is reduced more effectively, impaired peripheral circulation is bypassed
While undergoing a soapsuds enema, the client complains of abdominal cramping. The nurse should
lower the height of the enema bag
Which nursing intervention helps to prevent medication errors in children?
minimizing the use of verbal and telephone orders, carefully reading all labels for accuracy and checking expiration dates, recording the client's weight before carrying out the medication order
Which of these records can a nurse use to document info specific to the client's health in a story- like format?
narrative documentation
A client is being admitted for a total hip replacement. when is it necessary for the nurse to ensure that a medication reconciliation is completed?
on admission to the hospital and before transfer to a rehabilitation facility
A high protein diet is recommended for a client recovering from a fracture. the nurse recalls that the rationale for high protein diet is to do what
promote cell growth and bone union
A nurse is teaching a community group about the basics of nutrition. Someone asks why fluoride is added to drinking water. what should the nurse respond
promotes dental health, necessary element
What are the best ways for a nurse to be protected legally
provide care within the parameters of the state standards for nursing practice, document consistently and objectively, clearly document a client's non-adherence to the medical regimen
A nurse is providing morning hygiene to a bedridden client who was admitted for exacerbation of chronic obstructive pulmonary disease. what is the priority nursing intervention when the client becomes short of breath during the care?
put the client in high Fowler position
the nurse documents the data gathered during the assessment in a client's medical record. What should the nurse do to ensure that the data is meaningful to other healthcare providers?
record objective information using accurate terminology
A client has received a prescription for a medication that is delivered via a nebulizer. when teaching about the use of a nebulizer, the nurse should teach the client to do what?
seal the lips around the mouthpiece and breath in and out, taking slow, deep breaths
Which therapeutic communication technique involves using a coping strategy to help the nurse and client adjust to stress?
sharing humor
During the beginning phase of therapeutic relationship, why is a clear understanding of participant's roles important
the client needs to know what to expect from the relationship
In order to provide ideal therapeutic communication to patients, a health care facility provides interpreter services. Which statement regarding an interpreter is true
the interpreter should be able to interpret not only the language but also the culture
the nurse is caring for a client who got discharged from the hospital. the nurse finds that the client is having difficulty in determining which medications to take. what would be the best nursing intervention
the nurse recommends the client's pharmacy to re-label the medication in large letters
An older client asks "How do i know that all the meds that i take are safe?" What info should the nurse respond with
"Ask your healthcare provider how and when you should be taking your meds." "Check the name, dose, instructions about administration of drugs each time before leaving the pharmacy" "Inform your healthcare provider of the over the counter drugs, recreational drugs, and amount of alcohol you ingest"
a nurse is teaching an older client about proper medication use. which statement made by the client indicates the need for further education?
"I will use over-the- counter meds along with prescribed drugs"
a nurse teaches a patient about taking a sublingual nitroglycerin tablet. which part of the body identified by the patient indicates that the patent understand the teaching
"under my tongue"
An elderly adult with Parkinson's falls while going to the bathroom and gets hurt. the nurse taking care of the patient informs the primary healthcare provider. What step should the nurse take to alert the risk management system?
the nurse should document the incident in the occurrence report tool
What are common negligent acts of nurses found in the hospital setting?
Failure to notify the healthcare provider of problems, failure to follow the 6 rights of medication administration, failure to ensure the safety of a client with disequilibrium problems
For a client with difficulty swallowing, the nurse should crush which medication?
acetaminophen extra strength
After an amputation of a limb, a client begins to experience extreme discomfort in the area where the limb once was. What is the nurse's greatest concern at this time
addressing the pain
the nurse recognizes that a client is experiencing an anaphylactic reaction secondary to drug hypersensitivity. what action should the nurse take first?
administer oxygen