FUNDAMENTALS2

A nurse is teaching a client about progressing from a clear liquid diet to a full liquid diet. Which of the following food selections by the client indicates an understanding of the teaching? A. Cooked vegetables B. Bananas C. Pudding D. Yogurt with fruit

C. Pudding

A nurse manager overhears a nurse telling a client, "I will administer your medication by injection if you don't swallow your pills." The nurse manager should identify that the nurse is committing which of the following torts? A. Assault B. Defamation C. Battery D. Invasion of privacy

A. Assault

A nurse is preparing to provide tracheostomy care for a client. Which of the following actions should the nurse plan to take? A. Wear clean gloves while cleaning the inner cannula. B. Cut a 4 inch x 4 inch (10 cm x 10 cm) gauze pad to place under the flanges of the tracheostomy tube. C. Cleanse the skin around the stoma with full-strength hydrogen peroxide. D. Secure the tracheostomy in place with a collar that has hook-and-loop fasteners.

A. Wear clean gloves while cleaning the inner cannula.

A nurse is providing teaching to a client about reducing the adverse effects of immobility. Which of the following statements by the client indicates an understanding of the teaching? A. "I will perform ankle and knee exercises every hour." B. "I will have my partner help me change positions every 4 hours." C. "I will remove my antiembolic stockings while I am in bed." D. "I will hold my breath when rising from a sitting position."

A. "I will perform ankle and knee exercises every hour."

A home health nurse is teaching a client about home safety. Which of the following statements by the client indicates an understanding of the teaching? (Select all that apply.) A. "I will use the grab bars when getting in and out of the bathtub." B. "I need to have a fire escape plan with my family." C. "I need to check my medication expiration dates." D. "I need to set my hot water heater to 140 degrees Fahrenheit." E. "I will apply tape over frayed areas of electrical cords."

A. "I will use the grab bars when getting in and out of the bathtub." B. "I need to have a fire escape plan with my family." C. "I need to check my medication expiration dates."

A nurse is teaching a group of newly licensed nurses about the Braden scale. Which of the following responses by a newly licensed nurse indicates an understanding of the teaching? A. "The scale measures six elements." B. "The client's age is part of the measurement." C. "The higher the score, the higher the pressure injury risk." D. "Each element has a range from one to five points."

A. "The scale measures six elements.

A nurse is collaborating with a risk management team about potential legal issues involving client care. The nurse should identify that which of the following situations is an example of negligence? A. A nurse begins a blood transfusion without obtaining consent from a client. B. An assistive personnel prevents a client from leaving the facility. C. A nurse administers a medication without first identifying the client. D. An assistive personnel discusses client care in the facility cafeteria with visitors present.

A. A nurse begins a blood transfusion without obtaining consent from a client.

A nurse is assessing a client who received an IM antibiotic injection 15 min ago. Which of the following findings should the nurse identify as an indication of a possible anaphylactic reaction to the medication? A. A sharp decrease in blood pressure B. A feeling of swelling in the feet C. Pain at the injection site D. A sudden decrease in heart rate

A. A sharp decrease in blood pressure

A nurse is caring for a client who has pneumonia. Nurses' Notes Day 1, 1100: Client admitted from emergency department with a new diagnosis of pneumonia. Confirmed by chest x-ray and laboratory results. Reports dyspnea and exhibits shortness of breath at rest. Client is hypoxic, confirmed by oxygen saturation. Placed on oxygen at 2 U/min via nasal cannula. Congested cough, sputum specimen obtained and sent to the laboratory. Crackles heard on auscultation; breath sounds diminished The nurse is providing discharge teaching for the client and their caregiver. Which of the following information should the nurse include? Select all that apply. A. Adjust the oxygen flow rate as needed to ease breathing. B. Antibiotic therapy should be taken for 10 days. C. Store the oxygen cylinder wrench with the oxygen tank. D. Ensure the oxygen delivery system is at least 8 feet from any heat source.

A. Adjust the oxygen flow rate as needed to ease breathing. C. Store the oxygen cylinder wrench with the oxygen tank.

A nurse is planning to change a client's tracheostomy ties. Which of the following actions should the nurse take? A. Allow space for three fingers under the ties when securing. B. Use a quick-release knot to secure the ties. C. Extend the client's neck while securing the ties. D. Cut the old ties after the new ties are secured.

A. Allow space for three fingers under the ties when securing.

A nurse is planning care for a client who has a prescription for extremity restraints to both wrists. Which of the following actions should the nurse include in the plan of care? (Select all that apply.) A. Assess skin temperature and color before applying the restraints. B. Attach the client's restraints to the bed rail. C. Ensure that the client's bed is in the lowest position. D. Pad bony prominences before applying the restraints. E. Secure restraints to allow three fingers to slide under the restraints.

A. Assess skin temperature and color before applying the restraints. C. Ensure that the client's bed is in the lowest position. D. Pad bony prominences before applying the restraints.

A nurse is planning care for a client who is scheduled for an intravenous pyelogram. Which of the following actions is appropriate for the nurse to Include? A. Assist the client with a bowel cleansing B. Ensure the client is free of metal objects C. Administer 240 ml of oral contrast before the procedure D. Monitor the client for pain in the suprapubic region.

A. Assist the client with a bowel cleansing

A nurse is performing an eye assessment for a newly admitted client. Which of the following findings should the nurse expect? A. Eyelashes that curl slightly outward. B. Eyelids that blink involuntarily 30 to 35 times per minute. C. Pupils that are 8 to 9 mm in diameter. D. Corneas with an opaque appearance.

A. Eyelashes that curl slightly outward.

A nurse in a provider's office is caring for a client. Medical History Initial visit: Client reports a sedentary lifestyle. Client is lactose intolerant and denies taking vitamin supplements. Client is a nonsmoker. Client does not drink alcohol. Diagnostic Results Initial visit: Calcium 8.9 mg/dL (9 to 10.5 mg/dL) Phosphorus 3.4 mg/dL (3 to 4.5 mg/dL) Nurses' Notes Initial visit: Client instructed to take a calcium and vitamin D supplement and begin an exercise program, such as walking 3 times per week. 6-month follow-up: Client states they frequently forget to take their calcium and vitamin D. The nurse is reviewing the client's medical record. Which of the following findings places the client at risk for osteoporosis? (Select all that apply.) A. Lactose intolerant B. Smoking history C. Vitamin D level D. Phosphorous level E. Alcohol use F. Activity level

A. Lactose intolerant C. Vitamin D level F. Activity level

A nurse is caring for a client who is scheduled for a surgical procedure. Medical History 2 days before procedure: Client takes 80 mg of aspirin PO daily for antiplatelet effects. Client performs moderate intensity exercise for 150 min each week. Client reports an allergy to latex. Nurses' Notes Morning of procedure: Client reports taking aspirin 80 mg PO this morning with a sip of water. Diagnostic Results Hct 37% (37% to 47%) Hgb 12 g/dL (12 to 16 g/dL) WBC count 12,000/mm3 (5,000 to 10,000/mm3) Prothrombin time 21 seconds (11 to 12.5 seconds) Select the 4 findings that require immediate follow-up. A. Latex allergy B. Hct level C. Prothrombin time D. WBC count E. Preoperative medication F. History of weekly exercise

A. Latex allergy C. Prothrombin time D. WBC count E. Preoperative medication

A nurse is planning care for a client who has acute pain as a result of a pressure injury to the sacrum. Which of the following nonpharmacological interventions should the nurse include in the plan? A. Loosen the client's bed linens. B. Massage the client's sacrum. C. Provide bright lights in the client's room. D. Offer to play music in the client's room.

A. Loosen the client's bed linens.

A nurse is obtaining a health history from a client. Which of the following factors places the client at risk for cardiovascular disease? A. Metabolic syndrome B. Participation in competitive sports C. Family history of alcohol use disorder D. Hypotension

A. Metabolic syndrome

A nurse is assessing a client who is receiving a blood transfusion. The nurse notes lung crackles, hypoxia, and distended neck veins. Which of the following actions should the nurse take? (Select all that apply.) A. Place the client in high-Fowler's position. B. Administer oxygen to the client. C. Stop the transfusion. D. Obtain a prescription for a diuretic. E. Administer epinephrine to the client.

A. Place the client in high-Fowler's position. B. Administer oxygen to the client. C. Stop the transfusion.

A nurse in an emergency department is caring for a client who is unconscious and requires surgery. There is no one available to give consent for the treatment. Which of the following actions should the nurse take? A. Prepare the client for surgery. B. Contact the facility's ethics committee for guidance. C. Keep the client stable until a family member arrives to give consent. D. Obtain consent from the surgeon.

A. Prepare the client for surgery.

A nurse is preparing to reposition a client who has a lower back injury. Which of the following actions should the nurse take? A. Roll the client as one unit in a smooth, continuous motion. B. Flex the client's knees. C. Place the client's arms at their sides. D. Place the client on the side of the bed nearest the direction they will be turned.

A. Roll the client as one unit in a smooth, continuous motion.

A nurse is caring for a client who had a stroke and coughs frequently when swallowing. The nurse should request a referral to which of the following members of the interdisciplinary team? A. Speech-language pathologist B. Social worker C. Physical therapist D. Occupational therapist

A. Speech-language pathologist

A nurse is assessing a client who has left-sided weakness following a stroke. Which of the following findings is the nurse's priority? A. The client coughs frequently while eating. B. The client's blood pressure is 142/94 mm Hg. C. The client is consuming 25% of their meals. D. The client leans to the left side while sitting.

A. The client coughs frequently while eating.

A nurse is caring for a client who has dysphagia. When assisting the client during breakfast, which of the following actions by the client indicates the nurse should intervene? A. The client drinks their thickened juice with a straw. B. The client adjusts the head of their bed to 90°. C. The client takes frequent breaks while eating. D. The client tucks their chin when they swallow.

A. The client drinks their thickened juice with a straw.

A home health nurse is assessing the home environment of an older adult client who has osteoporosis. For which of the following findings should the nurse intervene? A. There is an area rug covering a tile floor. B. Grab bars are installed in the shower. C. Prescriptions are stored in a medication organizer. D. The hot water heater is set to 47° C (117" F).

A. There is an area rug covering a tile floor.

A nurse in a mental health clinic is caring for an older adult client who has depression and has stopped taking their medication. The client tells the nurse, "I want to die now that my partner is gone." Which of the following responses should the nurse make? A. "You should discuss these feelings with your provider." B. "Have you thought about harming yourself?" C. "Why did you stop taking your medication?" D. "Tell me more about your partner."

B. "Have you thought about harming yourself?"

A nurse is preparing to teach a female client about osteoporosis prevention. Which of the following recommendations should the nurse make for this client? A. "Maintain a lean body mass." B. "Walk for 30 minutes three to five times each week." C. "Increase intake of vitamin B12." D. "Perform water aerobics three times each week."

B. "Walk for 30 minutes three to five times each week."

A nurse is preparing to provide postmortem care for a client. Which of the following actions should the nurse plan to take? A. Turn overhead lights to a bright setting. B. Ask the family if they wish to assist in washing the client's body. C. Remove the client's dentures for their family to keep. D. Leave the client's eyes open until the family views the body.

B. Ask the family if they wish to assist in washing the client's body.

A nurse is caring for a client. Vital Signs 0800: Temperature 37.6° C (99.7 F) Blood pressure 108/56 mm Hg Heart rate 66/min Respiratory rate 18/min Pulse oximetry 97% on room air 0830: Temperature 37.5° C (99.5° F) Blood pressure 88/56 mm Hg Heart rate 104/min Respiratory rate 24/min Pulse oximetry 93% on room air Nurses' Notes 0800: Antibiotic administered as prescribed. Bilateral breath sounds clear and present throughout. 0830 Client reports itching over the chest area and has urticaria over chest and trunk. Client states tongue feels swollen Bilateral breath sounds with scattered wheezing upon auscultation, Select the 4 findings that require immediate follow-up. A. Heart rate B. Blood pressure C. Temperature D. Urticaria E. Swollen tongue F. Breath sounds

B. Blood pressure D. Urticaria E. Swollen tongue F. Breath sounds

To ensure client safety, a nurse manager is planning to observe a newly licensed nurse perform a straight catheterization on a client. In which of the following roles is the nurse manager functioning? A. Client educator B. Client advocate C. Client care provider D. Case manager

B. Client advocate

A nurse is caring for a client who is postoperative and is on bed rest. Which of the following actions should the nurse take to decrease the client's risk of developing a pressure injury? A. Massage the client's bony prominences. B. Ensure the client's heels are not touching the mattress. C. Raise the head of the client's bed to a 60° angle. D. Reposition the client every 4 hr.

B. Ensure the client's heels are not touching the mattress.

A nurse enters the room of a client who has a seizure disorder. The client is sitting in a chair and begins to experience a seizure. Which of the following actions should the nurse take first? A. Turn the client onto their side. B. Help the client lie on the floor. C. Loosen the client's clothing. D. Move items in the room away from the client.

B. Help the client lie on the floor.

A nurse is conducting the Weber's test on a client. Which of the following is an appropriate action for the nurse to take? A. Deliver a series of high-pitched sounds at random intervals. B. Place an activated tuning fork in the middle of the client's forehead. C. Hold an activated tuning fork against the client's mastoid process. D. Whisper a series of words softly into one ear.

B. Place an activated tuning fork in the middle of the client's forehead.

A nurse is collecting a blood pressure (BP) reading from a client who is sitting in a chair. The nurse determines that the client's BP is 158/96 mm Hg. Which of the following actions should the nurse take? A. Ensure that the width of the BP cuff is 50% of the client's upper arm circumference. B. Recheck the client's BP in her other arm for comparison. C. Request that another nurse check the client's BP in 30 min. D. Reposition the client supine and recheck her BP.

B. Recheck the client's BP in her other arm for comparison.

A nurse is caring for a client who has left lower-lobe atelectasis. In which of the following positions should the nurse place the client for postural drainage? A. Side-lying with the right side of the chest elevated B. Right lateral in Trendelenburg position C. Prone with pillows under the lower extremities D. Supine in low-Fowler's position

B. Right lateral in Trendelenburg position

A nurse is teaching a client how to self-administer daily low-dose heparin injections. Which of the following factors is most likely to increase the client's motivation to learn? A. The nurse explaining the need for education to the client. B. The client's belief that his needs will be met through education. C. The nurse's empathy about the client having to self-inject. D. The client seeking family approval by agreeing to a teaching plan.

B. The client's belief that his needs will be met through education.

A nurse is planning care for a client who is immobile. Which of the following actions should the nurse include in the plan of care? A. Logroll the client every 4 hr. B. Use trochanter rolls beside the client's legs. C. Place the client's arms at their side when turning them. D. Cross the client's ankles when lying supine.

B. Use trochanter rolls beside the client's legs.

A nurse is preparing to perform an anthropometric assessment on a client. Which of the following client data should the nurse include? A. Respiratory rate B. Weight C. Level of orientation D. Current pain level

B. Weight

A nurse is preparing to administer medications to a client. At which of the following times should the nurse compare the medication administration record and the medication label? (Select all that apply.) A. At the end of the shift B. When removing the medication from the medication drawer C. Directly before administering the medication D. When reconciling counts of controlled substances E. When preparing the medication dosage

B. When removing the medication from the medication drawer C. Directly before administering the medication D. When reconciling counts of controlled substances

A newly licensed nurse has forgotten their password and asks another nurse to access the computer system for them so they can document care before transferring the client to another unit. Which of the following responses should the nurse make? A. "See the supervisor so they can give you a temporary password." B. "Provide the client's information to the charge nurse, who can document the information for you." C. "I can give you the contact information for someone to assist you with recovering your password." D. "Under these circumstances, I can let you use my password just this one time."

C. "I can give you the contact information for someone to assist you with recovering your password."

A nurse is caring for a client who has a terminal illness. The client states, "I am not giving up. I want as much treatment as possible." Which of the following responses should the nurse make? A. "Hospice care is the best thing for you at this time." B. "Enjoy the time you have and do the things you want to do." C. "I will contact your provider to discuss your options." D. "You need to understand that you have very little time left."

C. "I will contact your provider to discuss your options."

A nurse is providing discharge teaching about safety considerations to an older adult client who lives at home. The client has heart failure and a new prescription for hydrochlorothiazide. Which of the following statements by the client indicates an understanding of the teaching? A. "I will weigh myself once weekly." B. "I will take my new medication in the evening." C. "I will leave a light on in my bathroom at night." D. "I will take a hot bath before going to bed."

C. "I will leave a light on in my bathroom at night."

A nurse is teaching a client who has decreased mobility about passive range-of-motion exercises. Which of the following statements should the nurse make? A. "I will move your joints to the point of mild pain." B. "I will move your joints quickly." C. "I will repeat these movements 3 to 5 times." D. "These movements will be performed once per day."

C. "I will repeat these movements 3 to 5 times."

A nurse is teaching an older adult client about reducing the risk for osteoporosis. Which of the following statements by the client indicates an understanding of the teaching? A. "I will avoid exposure to the sun." B. "I will decrease my intake of dairy products." C. "I will walk three times per week." D. "I will take 250 milligrams of calcium once per day."

C. "I will walk three times per week."

A home health nurse is caring for a client who has a chronic illness and recently moved in with their adult child. Which of the following statements by the client should indicate to the nurse that the client has adapted to their new situational role? A. "I'm looking forward to being able to be independent again." B. "I've never been the kind of person to ask others for help." C. "It's nice having other people cook for me." D. "I really don't know what I'm supposed to do all day."

C. "It's nice having other people cook for me."

A nurse is caring for an adolescent client who has full-thickness burns on their leg. The client expresses concern about their future. Which of the following is a therapeutic response by the nurse? A. "If you work hard on your physical therapy, you won't need to worry." B. "You shouldn't worry about the future so you can concentrate on getting well." C. "You're concerned about what will happen when you leave the hospital." D. "Why are you concerned even though everyone is here to help you?"

C. "You're concerned about what will happen when you leave the hospital."

A nurse is caring for a client who reports that she has insomnia. Which of the following interventions is appropriate for the nurse to recommend? A. Drink a cup of hot cocoa before bedtime. B. Exercise 1 hr before bedtime. C. Eat a light carbohydrate snack before bedtime. D. Take a 30-min nap daily.

C. Eat a light carbohydrate snack before bedtime.

A nurse is caring for a client who has a colostomy. Which of the following actions should the nurse take? A. Rub the peristomal skin dry after cleaning. B. Change the pouch once every 24 hr. C. Ensure the pouch is 0.32 cm (1/8 in) larger than the stoma. D. Apply the pouch while the skin barrier is still damp.

C. Ensure the pouch is 0.32 cm (1/8 in) larger than the stoma.

A nurse is caring for a client who requires airborne precautions. The nurse is preparing to leave the client's room following a dressing change. Which of the following pieces of personal protective equipment should the nurse remove first? A. Eyewear B. Mask C. Gloves D. Gown

C. Gloves

A nurse is caring for a client who is scheduled for surgery. Diagnostic Results 1000: Prealbumin level 13 mg/dL (15 to 36 mg/dL) Cholesterol 210 mg/dL (less than 200 mg/dL) Fasting glucose 110 mg/dL (70 to 110 mg/dL) Medical History 0800: The client has a history of malnutrition, hyperlipidemia, and diabetes mellitus. Mini Nutritional Assessment screening tool score of 7 points (0 to 14 points) The nurse is reviewing the client's medical record. Which of the following findings places the client at risk for delayed wound healing? Select all that apply. A. Mini Nutritional Assessment screening tool score B. History of hyperlipidemia C. History of malnutrition D. History of diabetes mellitus E. Cholesterol level F. Prealbumin level

C. History of malnutrition D. History of diabetes mellitus F. Prealbumin level

A nurse is preparing to set up a sterile field. Which of the following actions should the nurse take? A. Hold bottles of sterile solution with the label in the palm of the hand. B. Pour liquids into containers outside the sterile field. C. Place the sterile field at the level of the nurse's hips. D. Open the outermost flap of the sterile kit toward the body.

C. Place the sterile field at the level of the nurse's hips.

A nurse is planning care for a client who has a new prescription for parenteral nutrition (PN) in 20% dextrose and fat emulsions. Which of the following is an appropriate action to include in the plan of care? A. Obtain a random blood glucose daily. B. Change the PN infusion bag every 48 hr. C. Prepare the client for a central venous line. D. Administer the PN and fat emulsion separately.

C. Prepare the client for a central venous line.

A nurse is admitting a client who is at risk for falls to a medical-surgical unit. Which of the following actions should the nurse take? A. Elevate full-length side rails on both sides of the client's bed. B. Place the bedside table 0.9 m (3 feet) away from the bed. C. Provide the client with a night light. D. Keep the client's room temperature at 18° C (64.4" F).

C. Provide the client with a night light.

A nurse is caring for a client who is anxious about being admitted to a health care facility for the first time. Which of the following statements should the nurse make? A. "You have nothing to worry about. Everything will be fine." B. "Most people are scared their first time in a health care facility." C. "Why are you feeling scared about being in this facility?" D. "We can discuss what you can expect during your stay."

D. "We can discuss what you can expect during your stay."

A nurse is caring for a client who has dysphagia and is receiving oral medications. Which of the following actions should the nurse take? A. Assist the client into semi-Fowler's position. B. Give the client's medications between meals. C. Encourage the client to use a straw to take the medications. D. Administer the client's medications one at a time.

D. Administer the client's medications one at a time.

A nurse is preparing to administer packed RBCs to a client who has a low hemoglobin level. Which of the following actions should the nurse take prior to the start of the infusion? A. Prime the client's primary IV tubing with lactated Ringer's. B. Confirm the identity of the client with the blood bank technician. C. Check that the client has a small gauge IV catheter in place. D. Check the blood product's compatibility with the client's blood type.

D. Check the blood product's compatibility with the client's blood type.

A nurse is prioritizing care for a client. Which of the following procedures should the nurse perform first? A. Urinary catheter care B. Enteral feeding C. Wound irrigation D. Endotracheal suctioning

D. Endotracheal suctioning

A nurse is teaching a client how to self-administer heparin. Which of the following instructions should the nurse include in the teaching? A. Use an 18-gauge, 1-inch needle to administer the medication. B. Massage the injection site after withdrawing the needle. C. Inject 5.1 cm (2 in) away from the umbilicus. D. Expel air bubble before injecting medication.

D. Expel air bubble before injecting medication.

A nurse is teaching a client who can only bear weight on one leg how to ambulate using crutches. Which of the following crutch gaits should the nurse plan to instruct the client to use? A. Two-point alternating gait B. Four-point alternating gait C. Swing-through gait D. Three-point gait

D. Three-point gait