Fundamentals Review Final

A nurse is admitting a client who requires droplet precautions due to influenza. Which of the following actions should the nurse take?

Wear a mask when providing care for the client

A nurse is teaching a client who has a history of falls about home safety. Which of the following statements should the nurse identify as an indication that the client understands the instructions?

"I will place a bath seat in my shower to use when I bathe"

A nurse at an extended-care facility is instructing a class of assistive personnel about client use of assistive devices during ambulation. Which of the following instructions should the nurse give the APs about the clients' use of a cane?

When the client moves, he should move the can forward first

A nurse is assisting a newly licensed nurse with delegating tasks to an assistive personnel on the unit. Which of the following statements by the nurse explains the purpose of delegation?

"Delegation permits a designated individual to meet a goal on your behalf."

A nurse is preparing to witness informed consent for a client who is preoperative. The client asks the nurse, "Are there other options besides surgery?" Which of the following responses should the nurse make?

"Have you discussed other treatments with your provider?"

A nurse us assisting a client who has received crutches in an urgent care center following a foot injury. Which of the following statements should the nurse identify as an indication that the client needs further teaching?

"I have a set of my brother's crutches in my basement I can also use"

A nurse is teaching an older adult client who has left-sided weakness about cane use. Which of the following instructions should the nurse include?

"When walking, move your left foot forward first"

A nurse is bathing a toddler and notices that she has several bruises. Which of the following actions should the nurse take first?

Ask the parents what caused the bruises

A charge nurse is delegating tasks to nursing personnel on a 10-bed medical-surgical nursing unit. Which o the following assignments is an example of overdelegation?

Assigning the most efficient AP to perform glucometer monitoring for each client

A nurse is providing dietary teaching for a client who takes furosemide. The nurse should recommend which of the following foods as the best source of potassium?

Bananas

A nurse is helping an older adult client ambulate in the hallway for the first time since admission. The client has brought her standard walker from home. To ensure proper use of the walker and the safety of the client, which of the following actions should the nurse take?

Check that the client lifts the walker and the places it down in front of her

A nurse is caring for a child who has tracheostomy. After suctioning the trach, the nurse should use which of the following findings to determine that the procedure was effective?

Clear breath sounds

A nurse is caring for a client who is scheduled for surgery. The nurse's role in regard to informed consent is which of the following?

Determining the client's level of understanding about the procedure

A nurse is preparing to measure a client's level of oxygen saturation and observes edema of both hands and thickened toe nails. The nurse should apply a pulse oximeter probe to which of the following locations?

Earlobe

A nurse is caring for a client whose informed consent form has been signed in preparation for a procedure. The client states, "I have decided not to have the procedure." Which of the following actions should the nurse take?

Inform the provider that the client is withdrawing consent

A nurse is caring for a group of clients. The nurse demonstrates adherence to ethical principle of fidelity by doing which of the following?

Keeping an appointment with a client

A nurse is planning care for a client who has dementia. Which of the following interventions should the nurse include in the plan of care?

Limit the client's choices for daily activities

A nurse is assisting with transferring a client from the bed to a wheelchair. Which of the following actions should the nurse take?

Lock the wheels of the bed and the wheelchair

A client smoking in his bathroom has dropped a cigarette butt into a wastepaper basket, which begins to smolder. Which of the following actions is the nurse's priority?

Move any clients in the immediate vicinity

A nurse is caring for a client with a trach. The client's partner has been taught to perform suctioning. Which of the following actions by the partner should indicate to the nurse a readiness for the client's discharge?

Performing the procedure independently

A nurse is giving a presentation about client confidentiality to a group of newly licensed nurses. Which of the following actions is an example of a violation of confidentiality?

Reporting laboratory findings to a member of the client's family

A nurse is monitoring a client who has a chest tube in place connected to wall suction due to a right-sided pneumothorax. The client complains of chest burning. Which of the following actions should the nurse take?

Reposition the client

A nurse checks with the assistive personnel on the unit throughout the shift to determine if they are completing tasks. The nurse is demonstrating which of the following rights of delegation?

Right supervision

A nurse is preparing to discharge a client who has an abdominal wound that is healing by secondary intention. Which of the following actions is the nurse's priority?

Schedule a follow-up visit by a home health nurse for dressing changes

A nurse is caring for a client who has a stage 3 pressure ulcer. The nurse should recognize that which of the following lab findings will affect wound healing?

Serum albumin 3.2g/dL

A nurse is teaching the parents of a 10-month-old infant about home safety. Which os the following information should the nurse include in the teaching?

Serve food in small, non-circular pieces Tie plastic bags in knots before discarding them Fit the mattress so that it is snug against the sides of the crib

A nurse is documenting information in a computerized health record. Which of the following nursing actions jeopardizes client confidentiality?

Sharing computer passwords with coworkers

A nurse manager is preparing to take disciplinary action for a staff nurse's substance use disorder. The manager should identify which of the following as having the authority to revoke a nurse's license?

State Board of Nursing

A nurse is caring for a client who has a hip fracture that requires surgical repair. Which of the following health care professionals is responsible for obtaining informed consent from the client for the procedure?

Surgeon

When planning delegation of tasks to an AP, a nurse considers the five rights of delegation. Which of the following should the nurse consider when using one of the five rights of delegation?

The AP has the knowledge and skill to perform the task

A nurse is caring for a client who has a history of dementia. The client is alert and oriented to person, place, and has advance directives. The client is scheduled for a procedure that requires informed consent. Which of the following persons should sign the informed consent

The client

A nurse is assessing a client's ability to ambulate with crutches using a three-point gait. Which of the following actions should the nurse identify as a risk to the client's safety?

The client places partial weight on the affected leg

A nurse is caring for a client who receives intermittent enteral feedings through an NG tube. Before administering a feeding, the nurse should measure the gastric residual for which of the following purposes?

To identify delayed gastric emptying

A nurse is providing oral care for a client who is immobile. Which of the follow actions should the nurse take?

Turn the client on his side before starting oral care

A nurse is in a client's room when the client begins having a tonic-clonic seizure. Which of the following actions should the nurse take first?

Turn the client's head to the side

A nurse is performing a mental status examination on a client who has a new diagnosis of dementia. Which of the following components should the nurse include?

Grooming Long-term memory Affect

A nurse is providing home safety information for an older adult client who uses a cane. Which of the following statements should the nurse include in the teaching?

"You should advance your weak leg forward to the cane, then move your strong leg"

A nurse is planning care for a 4-year-old child who requires airborne precautions. Which of the following activities should the nurse plan for the child?

Putting a large-piece puzzle together

A nurse is caring for a client who has named a person to serve as his health care proxy. The client states he needs clarification about his type of advance directive. Which of the following statements by the client indicates a need for clarification?

"I have to choose a family member as my health proxy"

A nurse is creating a discharge plan. Which of the following nursing statements indicates the nurse understands when discharge planning should be implemented

"I will begin upon the client's admission to the facility."

A nurse is providing discharge teaching to a client who was recently diagnosed with a latex allergy. Which of the following client statements indicates an understanding of the teaching?

"I will use ink pens for writing"

A nurse manager is providing an inservice program about delegation to an AP with staff nurses on the unit. Which of the following statements by a staff nurse indicates an understanding of the teaching?

"The nurse should consider the APs level of experience when making delegation decisions"

A nurse is providing preop teaching for a client who will undergo surgery. The nurse explains that the client will wear antiembolism stockings during and after the procedue. When the client asks what the stockings do, which of the following responses should the nurse make?

"They improve your circulation to keep blood from pooling in your legs"

A nurse is caring for a client who has DVT and has been on heparin continuous infusion for 5 days. The provider prescribes warfarin PO without discontinuing the heparin. The client asks the nurse why both anticoagulants are necessary. Which of the following statements should the nurse make?

"Warfarin takes several days to work, so the IV heparin will be used until the warfarin reaches a therapeutic level"

A nurse should teach which of the following clients requiring crutches about how to use a three-point gait?

A client who has a right femur fracture with no weight bearing on the affected leg

A charge nurse is reviewing guidelines for initiating airborne precautions. Which of the following clients should the nurse identify as requiring airborne precautions?

A client who has measles

A nurse is educating a group of older adults in a community center on weight management using the BMI scale. Using the client's height and weight to calculate BMI, which of the following clients has a healthy BMI?

A client with a weight of 150lb and height of 68in

A nurse is teaching a class on torts. The nurse should include which of the following situations is an example of negligence?

A nurse identifies the absence of peripheral pulsation in a casted extremity in the early morning and reports it to the provider in the early afternoon

A nurse is caring for a client who has returned to the unit following a surgical procedure. The client's oxygen saturation is 85%. Which of the following actions should the nurse take first?

Raise the head of the bed

A nurse is assessing a client who has COPD. The nurse should expect the client's chest to be which of the following shapes

Barrel

A nurse is caring for a client who has valvular heart disease and is at risk for developing left-sided heart failure. Which of the following manifestations should alert the nurse that the client is developing this condition?

Breathlessness

A nurse id caring for a client who is 12hr postop and has a chest tube to a disposable water-seal drainage system with suction. The nurse should intervene for which of the following observations?

Continuous bubbling in the water-seal chamber

A nurse is caring for a client who is 2 days postop following abdominal surgery and observes the the client's wound has eviscerated. After calling for help, which of the following actions should the nurse take first?

Cover the area with a sterile dressing, moistened with 0.9% sodium chloride irrigation

A nurse is caring for a client who has C. diff infection. Which of the following cleansing agents should the nurse use for hand hygiene?

Nonantimicrobial soap

A nurse is caring for a client who is postop following vascular surgery. Which of the following signs should indicate to the nurse that the client has developed a thrombus?

Dull, aching calf pain

A nurse has completed care procedures for a client who requires airborne precautions. Which of the following items of PPE should the nurse remove first?

Gloves

A nurse in a cardiac care unit is caring for a client with acute right-sided heart failure. Which of the following findings should the nurse expect?

Elevated central venous pressure (CVP)

A nurse is caring for a client who has COPD. The client tells the nurse, "I can feel the congestion in my lungs, and i certainly cough a lot, but I can't seem to bring anything up." Which of the following actions should the nurse take to help this client with tenacious bronchial secretions?

Encouraging the client to drink 2 to 3 L of water daily

A nurse is providing discharge teaching to a client who has a new diagnosis of heart failure. Which of the following instructions should the nurse include in the teaching?

Exercise at least three times per week

A nurse is caring for a postop client who has a chest tube connected to the suction and a water seal drainage system. Which of the following indicates to the nurse that the chest tube is functioning properly?

Fluctuation of the fluid level within the water seal chamber

A nurse is caring for a client who has impaired mobility. Which of the following support devices should the nurse plan to use to prevent the client from developing plantar flexion contractures?

Footboard

A nurse is assessing a client who has left-sided heart failure. Which of the following findings should the nurse expect?

Hacking cough

A nurse is assessing a client who has right ventricular failure. Which of the following findings should the nurse expect?

Hepatomegaly

A nurse is caring for a client who is experiencing a seizure. Which of the following actions should the nurse take?

Loosen restrictive clothing Place a pillow under the client's head

A nurse is measuring a client for knee-high anti-embolic stockings to help prevent venous stasis. Which of the following actions should the nurse take?

Measure from the heel to the popliteal space

A nurse plans to leaver her scheduled shift an hour early without permissions or notification of the charge nurse. The clients in the nurse's assignment are stable. Which of the following legal torts applies to this situation?

Negligence

A nurse is assessing a client who has a urine output of 250ml in a 24-hr period. Which of the following descriptive terms should the nurse place in the client's electrrnic record

Oliguria

A nurse is completing discharge planning for a client who has bacterial endocarditis. The client will need to receive 12 weeks of antibiotic therapy. Which of the following venous access devices should the nurse identify as appropriate for the client?

Peripherally inserted central catheter

A nurse is planning care for a client who has manifestations of C. diff infection. Which of the following actions should the nurse plan to take?

Place the client on contact precautions

A nurse is caring for a client who has heart failure and a new prescription for furosemide. Which of the following laboratory values should the nurse review before administering furosemide?

Potassium

A client is planning to perform nasotracheal suction for a client who has COPD and an artificial airway. Which of the following actions should the nurse take?

Preoxygenate the client with 100% oxygen for up to 3min

A nurse is obtaining informed consent from a client who is postop. Which of the following actions should the nurse take?

Validate the signature is authentic Verify the client understands the surgical procedure Confirm that the consent is voluntary

A nurse arrives for her shift and is preparing to count the controlled substances in the secure cabinet. Which of the following actions should the nurse take?

Verify the amounts of each medication she counts match the amounts on the inventory record

A home health nurse is conducting a home safety assessment for an adult client. Which of the following findings should the nurse identify as a safety risk for the client?

Water heater temp. 54.4 degree celcius (130 degree fahrenheit) Throw rugs

A nurse is caring for a client who is dying. The nurse should incorporate the principle of nonmaleficence into practice by taking which of the following actions?

Withholding a dose of narcotic pain medication when the client has respiratory depression