Fundamentals Practice Test B

A nurse enters a client's room and finds her on the floor. The client's roommate reports that the client was trying to get out of bed and fell over the side rail onto the floor. Which of the following statements should the nurse document abut this incident?

"Client found lying on floor"

A nurse is discussing the use of herbal supplements for health promotion with a client which of the following client statements indicates an understanding of herbal supplement use?

"I can take echinacea to improve my immune system"

A nurs eis preparing to obtain a lower extremity BP from a client and no longer palpates the popliteal pulse after 92 mm Hg. Which of the following images displays the measurement in mm Hg to which the nurse should inflate the cuff when obtaining the BP?

120 mm Hg

A nurse is calculating a client's fluid intake over the past 8 hr. Which of the following items should the nurse plan to document on the client's intake and output record as 120 mL of fluid?

8 oz of ice chips

A nurse is teaching a group of staff nurses about the use of essential oils for aromatherapy. The nurse should include in the teaching that this therapy might be contraindicated for which of the following clients?

A client who has asthma

A community health nurse is checking BPs for a group of clients at a community health screening. Which of the following clients is at an increased risk for HTN?

A client who smokes one pack of cigarettes each day

A nurse is preparing to delegate client care tasks to an AP. Which of the following tasks should the nurse delegate?

Ambulating a client who is post-op

A nurse has just inserted an NGT for a client. Which of the following findings should the nurse expect to confirm correct tube placement?

An x-ray shows the end of the tube above the pylorus Rationale: an abdominal x-ray should be the first option for a newly placed NGT

A nurse is caring for a client who has decreased mobility. Which of the following actions should the nurse take to decrease the client's risk of developing plantar flexion contractures?

Apply an ankle-foot orthotic device to the client's feet

A nurse is planning care for a client who has vision loss. Which of the following interventions should the nurse include in the plan of care to assist the client with feeding?

Arrange food in a consistent pattern on the client's plate

A nurse is preparing to transfer a client who can bear weight on one leg from the bed to a chair. After securing a safe environment, which of the following actions should the nurse take next?

Assess the client for orthostatic hypotension

A nurse is administering IV fluids to a client. When monitoring for adverse effects, which of the following assessments should the nurse identify as the priority?

Auscultate lung sounds

A nurse is caring for a client who has an indwelling urinary catheter. Which of the following findings indicates that the catheter requires irrigation?

Bladder scan shows 525mL of urine

A nurse providing D/C teaching for a client who has a new Rx for a home oxygen concentrator. Which of the following instructions should the nurse provide to the client and his family? (Select all that apply)

Check the cord routinely for frays or tearing Consider purchasing a generator for power backup Observe for signs of hypoxia

A nurse is caring for a client who has a prescription for wound irrigation. Which of the following actions should the nurse take?

Cleanse the wound from the center outward

A nurse on a medical unit is preparing to D/C a client to home. Which of the following actions should the nurse take as part of the medication reconciliation process?

Compare prescriptions with medications the client received while at the facility

A nurse in an acute care facility is preparing a D/C summary for a client who is transferring to a long-term care facility. Which of the following documentation should the nurse include?

Current medications

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

Droplet

A nurse is assessing an adult client who has been immobile for the past 3 weeks. For which of the following findings should the nurse intervene?

Erythema on pressure points Rationale: erythema on pressure points require prompt relief of pressure and additional measures to protect the skin from breakdown

A client who is non ambulatory notifies the nurse that his trash can is on fire. After the nurse confirms the presence of the fire, which of the following actions should the nurse take next?

Evacuate the client

A nurse is preparing to administer multiple medications to a client who has an enteral feeding tube. Which of the following actions should the nurse plan to take?

Flush the tube with 15mL of sterile water

A nurse is preforming a Romberg test during the physical assessment of a client. Which of the following techniques should the nurse use?

Have the client stand with their arms at their sides and their feet together Rationale: identifies alterations in balance

A nurse is caring for a client who has limited mobility in his lower extremities. Which of the following actions should the nurse take to prevent skin breakdown?

Have the client use a trapeze bar when changing position

A nurse is caring for a client who is receiving pain medication through a PCA pump. Which of the following actions should the nurse take?

Instruct the family to refrain from pushing the button for the client while she is asleep

A nurse is reviewing a client's medication prescription that reads, "digoxin 0.25 by mouth every day." Which of the following components of the prescription should the nurse verify with the provider?

Medication dose

A nurse is planning care for a client who has TB. The nurse should use which of the following pieces of PPE when providing care for the client?

N95 respirator

A nurse is planning teaching for a group of adolescents who each recently had surgical placement of an stony. Which of the following methods should the nurse use as a psychomotor approach to learning?

Practice sessions Rationale: practice sessions require psychomotor skills when learning

A nurse is completing an admission assessment for a client who reports vomiting and diarrhea for the past 3 days. Which of the following findings should the nurse expect?

Rapid HR

A nurse is reviewing protocol in preparation for suctioning secretions from a client who has a new tracheostomy. Which of the following actions should the nurse plan to take?

Select a suction catheter that is half the size of the lumen

A nurse is caring for a client who is receiving fluid through a peripheral IV catheter Which of the following findings at the IV site should the nurse identify as indicating infiltration?

Skin blanching

A nurse is caring for a client who requires an informed consent for a surgical procedure. Which of the following actions is the nurse's responsibility?

Witness the client's signature on the consent form

A nurse is admitting a client who has been having frequent tonic-clonic seizures. Which of the following actions should the nurse add to the client's plan of care?

Wrap blankets around all four sides of the bed

A nurse is caring for a client who requires 24-hr urine collection. Which of the following statements by the client indicates understanding of the teaching?

"I flushed what I urinated at 7:00 a.m. and have saved all urine since"

A nurse is caring for a client who has recently started using a behind-the-ear hearing aid. Which of the following statements should the nurse identify as an indication that the client understands the use of this assistive device?

"I will be sure to remove my hearing aid before taking a shower"

A nurse is caring for a client who reports difficulty falling asleep. Which of the following recommendations should the nurse make?

"Maintain a consistent time to wake up each day"

A middle adult client tells the nurse, "I feel so useless now that my children do not need me anymore." Which of the following responses should the nurse make?

"People in the middle adulthood often find satisfaction in nurturing and guiding young people"

A nurse is caring for a client who reports pain. When documentation the quality of the client's pain on an initial pain assessment, the nurse should record which of the following client statements?

"The pain is like a dull ache in my stomach"

A nurse is caring for a client who has terminal Dx and whose health is declining. The client requests information about advanced directives. Which of the following responses should the nurse make?

"We can talk about advanced directives, and I can also give you some brochures about them"

A nurse is caring for a client who has terminal liver CA. Which of the the following statements should the nurse identify as an indication that the client is experiencing spiritual distress?

"What could I have done to deserve this illness?"

A nurse is teaching a client whose left leg is in a cast about using crutches. Which of the following statements should the nurse identify as an indication that the client understands the teaching?

"When descending stairs, I will first shift my weight to my right leg"

A nurse in a clinic is caring for a middle adult client who states, "The doctor says that, since I am at an average risk for colon CA, I should have a routine screening. What does that involve?" Which of the following responses should the nurse make?

"You should have a fecal occult blood test every year"

A nurse has accepted a verbal Rx "for three tenths of a milligram of levothyroxine IV stat" for a client who has myxedema coma. How should the nurse transcribe the dosage of this medication in the client's medical record?

0.3 mg

A nurse is preparing a heparin infusion for a client who was admitted to the facility with DVT. The order reads: 25,000 U of heparin in 0.9% sodium chloride 250 mL to infuse at 800 U/hr. At what rate should the nurse set the infusion pump? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

8 mL/hr

A nurse is caring for a group of client on a med/surg unit. In which of the following situations does the nurse demonstrate the ethical principle of veracity?

A client who is unaware of her recent CA Dx asks the nurse if she has CA, and the nurse responds affirmatively

A nurse manager is overseeing the care activities on a unit. For which of the following situations should the nurse manager intervene due to a violation of HIPAA guidelines?

A nurse asks a nurse from another unit to assist with documentation for a client

A nurse is giving change of shift report about a client they admitted earlier that day who has pneumonia. Which of the following pieces of information is the priority for the nurse to provide?

Breath sounds

A nurse is assessing a client who received an IV fluid bolus for dehydration. Which of the following findings should the nurse identify as an indication of fluid volume excess?

Distended neck veins

A nurse is preparing to administer 0.5 mL of oral single-dose liquid medication to a client. Which of the following actions should the nurse take?

Gently shake the container of medication prior to administration

A charge nurse is discussing the responsibility of nurses caring for clients who have C-diff infection. Which of the following should the nurse include in the teaching?

Have the family members wear a gown and gloves when visiting

A nurse is reviewing practice guidelines with a group of newly licensed nurses. Which of the following interventions should the nurse include that is within the RN scope of practice?

Initiate an enteral feeding through a gastrostomy tube

A nurse is caring for a client who has a Rx for 5 U of regular insulin and 10 U of NPH insulin to mix together and administer subq. Determine the correct order of steps for this procedure.

Inject 10 U of air into the bottle of NPH insulin Inject 5 U of air into the bottle of regular insulin Withdraw the correct dose of regular insulin from the bottle Withdraw the correct dose of NPH insulin from the bottle

A nurse is preforming a peripheral vascular assessment for a client. When placing the bell of the stethoscope on the client's neck, the nurse hears the following sound. This sound indicates which of the following? (Audio clip)

Narrowed arterial lumen

A nurse is caring for a client who has TB. Which of the following actions should the nurse take? (Select all that apply)

Place the client in a room with negative-pressure airflow Wear gloves when assisting the client with oral care Use antimicrobial sanitizer for hand hygiene

A nurse is caring for a client who has an NGT and is receiving intermittent feedings through an open system. Which of the following actions should the nurse take first?

Tell the client to keep the head of the bed elevated at least 30 degrees Rationale: the first action the nurse should take when using ABCs is to prevent aspiration of the enteral formula

A home health nurse is completing an admission assessment of an older client who has their caregiver present. Which of the following findings should the nurse identify as a potential indication of elder abuse?

The caregiver insists on remaining in the room

A charge nurse is observing a newly licenses nurse preparing a sterile field for a dressing change. Which of the following actions by the newly licensed nurse requires intervention by the charge nurse?

The newly licensed nurse places the cap of a bottle of sterile saline solution on the sterile field

A nurse is teaching an older adult client who is at risk for osteoporosis about beginning a program of regular physical activity. Which of the following types of activity should the nurse recommend?

Walking briskly

A nurse is caring for a client who is refusing a blood transfusion for religious reasons. The client's partner wants the client to have the blood transfusion. Which of the following actions should the nurse take?

Withhold the blood transfusion

A nurse in a surgical suite notes documentation on a client's medical record that he has a latex allergy. In preparation for the client's procedure, which of the following precautions should the nurse take?

Wrap monitoring cords with stockinette and tape them in place