Missed Fundamental Questions

A nurse is measuring the blood pressure of several clients. which of the following results is within the expected reference range for blood pressure?

116/70 mmHg

A nurse is teaching a middle-aged female client about disease prevention and health maintenance. which of the following diagnostic tests should the nurse recommend as part of the client's routine screening?

Eye examination every 2 years, check for gluacoma

A nurse is changing the dressing for a client recovering from an appendectomy following a ruptured appendix. the client surgical wound is healing by secondary intention. which of the following observation should the nurse report to the provider?

Halo of erythema on the surrounding skin The nurse should report to the provider when the client has a ring of erythema (redness) on the surrounding skin, which might indicate underlying infection. this and any other manifestations of infection should be reported to the provider

A nurse is preparing to administer an otic antibiotic to an adult client who is otitis media. Which of the following actions should the nurse plan to take?

Hold the dropper 1 cm (0.5 in) above the ear canal during administration

A nurse is caring for a client who is 48 hr postoperative following a small bowel resection. The client reports gas pains in the periumbilical area. The nurse should plan care based on which of the following factors contributing to this postoperative complication?

Impaired peristalsis of the intestines Normal bowel function is delayed for up to several days following a bowel resection. When peristalsis is absent or sluggish, intestinal gas builds up, producing pain and abdominal distension. The nurse should plan to help the client ambulate to promote peristalsis.

A nurse is preparing to administer a bolus feeding to a client through an NG tube and observes that the exit mark on the tube has moved since the last feeding. which of the following actions should the nurse plan to take?

request an X-ray of the clients abdomen.

A nurse is planning care for a client who has anorexia and nausea due to cancer treatments. Which of the following interventions should the nurse include?

Limit drinking liquids with food

A nurse in the emergency department is assessing a client who has deep, rapid respirations. Arterial blood gas analysis includes the following values, pH 7.25, PaCO2 40, and HCO3 18. Which of the following acid-base imbalances should the nurse identify and report to the provider?

Metabolic acidosis

A nurse is using the Braden scale to predict the pressure ulcer risk of a client in a long-term care facility. using the scale, which of the following parameters should the nurse evaluate?

Nutrition. nutrition, sensory perception, moisture, activity, mobility, friction and shear are the parameters on the Braden scale for determining the client's risk of developing pressure ulcers

A nurse is called away for an emergency while conversing with a client who is concerned about his medical diagnosis. the nurse returns to the client promptly, as promised. which of the following ethical principles is the nurse demonstrating?

The nurses is demonstrating the ethical principle of Fidelity by keeping a promise that was made

A newly licensed nurse is preparing to administer medications to a client. the nurse notes that the provider has prescribed a medication that is unfamiliar to him. which of the following actions should the nurse take?

consult the medication reference book available on the unit

A nurse is caring for a client who is producing large amounts of urine. the nurse should document this finding as which of the following?

diuresis/polyuria

A nurse is caring for an adult client who has an NG tube in place and a prescription for continuous enteral feedings. Which of the following actions should the nurse perform to reduce the client's risk of aspiration?

elevate the head of the bed by 30° or 45°

A nurse is removing personal protective equipment after performing a procedure for a client who requires isolation precautions. which of the following items a PPE should the nurse remove first?

gloves

A nurse is reviewing the use of side rails with an assistive personnel. which of the following statements by the AP Indicates that further teaching is required?

if the client seems confused, I'll raise all four side rails so that he doesn't hurt himself. Raising all four side rails can put the client at greater risk for injury. for example, the client might try to climb over the side rails, which could result in a fall

A nurse is cleaning a client's wound by swabbing from the area of least contamination to an area of greater contamination. which of the following rationale should the nurse identify for using this technique?

keeping microorganisms from entering the wound

A nurse is assessing the heart sounds of a client who has developed chest pain that worsens with inspiration. the nurse also takes a high-pitched scratching sound during both systole and diastole with the diaphragm of the stethoscope positioned at the left sternal border. which of the following heart sound should the nurse document?

pericardial friction rub A pericardial friction rub is a manifestation of pericardial inflammation and can be heard with infective pericarditis with myocardial infarction, following cardiac surgery or trauma

A nurse is caring for a client who is receiving intermittent enteral feedings through an NG tube. The specific gravity of the client's urine is 1.035. Which of the following actions should the nurse take?

provide more water with feedings. The elevation in the client specific gravity indicates dehydration. the nurse should Provide more fluids either by adding free water to feedings or by instilling water between feedings

A nurse is planning care for a client who is confused and requires a prescription for wrist restraints. Which of the following intervention should the nurse include in the plan of care?

renew the prescription for the use of restraints within 24 hours

A nurse is planning to perform passive range of motion exercises for a client. Which of the following actions should the nurse take?

repeat each joint motion five times during each session

A nurse is caring for a client who has xerostomia (dry mouth) with a lack of saliva. Which of the following nutrients will be affected by the lack of salivary amylase?

starch

The client is being discharged home with oxygen therapy delivered through a nasal cannula. Which of the following instructions should the nurse provide to the client and family members?

wear cotton clothing to avoid static electricity The use of cotton clothing will limit the buildup of static electricity. oxygen is a highly combustible gas. the use of oxygen in high concentrations has great combustion potential and readily fuels fire.