Nursing Fundamentals I Final Exam

Which question about fluid balance would be most appropriate when conducting a health history for a client? "How did you feel when your calcium was low?" "Describe your problems with constipation." "Do you eat fruits and vegetables each day?" "Describe your usual urination habits."

"Describe your usual urination habits."

The nurse is conducting an assessment of a client that has been admitted to a medical unit in the hospital for treatment of pneumonia. When conducting the respiratory assessment of this client the nurse will - Auscultate the chest for breath sounds. - Apply supplemental oxygen by face mask as needed. - Document "impaired oxygenation" on the nursing care plan. - Collaborate with the client to form goals.

Auscultate the chest for breath sounds.

In an Urgent Care Clinic the nurse auscultates lung sounds of a client complaining of cough and congestion. Which type of assessment is the nurse performing? Comprehensive Focused General Emergency

Focused

Which of the following is NOT an element in the development or chain of infection? - Reservoir for pathogen to grow - Infectious agent or pathogen - Mode of transmission - Formation of immunoglobulin

Formation of immunoglobulin

The nurse is caring for a client with chronic obstructive pulmonary disease (COPD) who expresses concerns about the ability to breathe easier. The nurse will suggest which position to help alleviate the client's dyspnea? Lying with the head slightly lowered High Fowler's position Side-lying with head slightly elevated Supine with one pillow

High Fowler's position

The charge nurse is observing a new nurse perform an assessment of a client's head and neck. Which action, if observed, would require the charge nurse to intervene - Palpation of both carotid arteries at the same time - Placing a tongue blade while asking the client to say 'ahh' - Occlusion of one of the client's nostrils while the client breathes through the nose - Warming of a stethoscope before assessing a client's breath sounds

Palpation of both carotid arteries at the same time

During diastole the following valves are open: (select 2 answers) Tricuspid Mitral Aortic Pulmonic

Tricuspid Mitral

A college-aged student has influenza. At what stage of the infection is the student most infectious? convalescent period incubation period prodromal stage full stage of illness

prodromal stage

The health care provider has recommended the client have a surgical procedure performed. The surgery would allow the client's problem to resolve quicker. Without surgery, healing would be delayed. The client states, "I do not want the surgery done." What is an appropriate response by the nurse? - "The health care provider believes the surgery is necessary." - "I would want the surgery done in order to heal sooner." - "Tell me the reason you do not want the surgery." - "You should have the surgery performed. You will get better quicker."

"Tell me the reason you do not want the surgery."

The nurse must use appropriate interviewing techniques to elicit accurate and complete health information. Which statement is an example of an open-ended question or comment? - "Are you having pain right now?" - "You seem upset today. Are you?" - "I'll be back in 30 minutes to check on your pain relief." - "What brought you to the hospital this morning?"

"What brought you to the hospital this morning?"

A client is admitted to a facility for treatment of pneumonia. Since admission, she has been unwilling to participate in care offered by the nursing staff but is too weak to provide her own care. The nurse is planning care for this client with a diagnosis of Bathing/Hygiene: Self-Care Deficit. What would the priority nursing intervention be? - Postpone hygiene activities until the client is feeling better - Assess the skin every day using the Braden scale. - Delegate hygiene/bathing to an unlicensed assistive personnel (UAP). - Assess the client's cultural views regarding hygiene and self-care.

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A cyclist reports to the nurse that he is experiencing pain in the tendons and ligaments of his left leg, and the pain is worse with ambulation. The nurse will document this type of pain as: somatic pain. cutaneous pain. visceral pain. phantom pain.

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A nurse is caring for a client who suddenly begins to have respiratory difficulty. In what position would the nurse place the client to facilitate respirations? High-Fowler's Prone Dorsal recumbent Supine

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Which types of data would be collected during a head to toe assessment? - Specific allergies resulting in itching - History of pain - Color, moisture, and temperature of the skin - Foods eaten that cause nausea

Color, moisture, and temperature of the skin

The home care nurse visits a client who has dyspnea. The nurse notes the client has pitting edema in his feet and ankles. Suspecting fluid overload, which additional assessment would the nurse expect to observe? Wheezing in the upper lobes Inspiratory stridor Crackles in the lower lobes Expiratory stridor

Crackles in the lower lobes

During an assessment of the cranial nerves, the nurse asks the client to smile, frown, wrinkle the forehead, and puff out the cheeks. Which nerve is being tested by this action? Cranial nerves II and III Cranial nerve VII Cranial nerve VIII Cranial nerve I

Cranial nerve VII

What assessment technique would the nurse use to assess a client's chest for color, shape, or contour? Percussion Palpation Auscultation Inspection

Inspection

A nurse knows that the expression "Do not cause harm" refers to which ethical principle? Beneficence Fidelity Justice Nonmaleficence

Nonmaleficence

During an annual performance review with an employee, the nurse manager does not maintain eye contact and seems concerned about the time and the next appointment. What type of communication is the manager exhibiting? Nonverbal Clarifying Verbal Consistent

Nonverbal

A nurse is admitting a client to a geriatric medicine unit. Which nursing action would the nurse perform to help reduce the client's risk for a fall? Provide the client with a bedpan to reduce ambulating to the restroom. Orient the client to the room and environment upon admission. Place the client in a shared room with a client who is alert. Administer pain medications sparingly in order to minimize any cognitive side effects.

Orient the client to the room and environment upon admission.

The nurse is taking care of a group of medical-surgical patients. Which patient is most at risk for developing an infection? - Observation status patient being monitored for chest pain - Patient recovering after right total hip replacement surgery - Patient admitted for dehydration - Patient admitted for stabilization of heart problems

Patient recovering after right total hip replacement surgery

The nurse is gathering data on a patient. Which data will the nurse report as objective data? - Patient states "I don't feel well" - Patient's respiratory rate is 16 - Patient is complaining of nausea - Patient reports a headache for the last 2 days

Patient's respiratory rate is 16

According to Maslow's basic human needs hierarchy, which needs are the most basic? Love and belonging Physiologic Safety and security Self-esteem

Physiologic

When a patient on respiratory isolation must be transported to another part of the hospital, the nurse: -Instructs the patient to cover his or her mouth and nose with a tissue when coughing or sneezing -Obtains a healthcare provider's order to prohibit the patient from being transported -Places a droplet mask on the patient before leaving the room -Advises other healthcare team members to wear gowns and gloves when coming in contact with the patient

Places a droplet mask on the patient before leaving the room

Which technique should the nurse use to best implement infection control in the home health visit? Wear gloves at all times when in the client's home or traveling in the car. Avoid touching any object in the home, including door knobs during the visit Take prescribed antibiotics on a regular basis on working days. Practice hand hygiene when beginning and ending the home visit.

Practice hand hygiene when beginning and ending the home visit.

The nurse is auscultating heart sounds and listens at the second left intercostal space along the left sternal border. Which valve is heard best at this location? Tricuspid Aortic Pulmonic Mitral

Pulmonic

Interpret this ABG: pH 7.33 PCO2 49 HCO3 26 Metabolic acidosis Metabolic alkalosis Respiratory alkalosis Respiratory acidosis

Respiratory acidosis

When performing an assessment on an older adult client, the nurse discovers that the client needs a cane when walking and has problems seeing at night. Under which stage of Maslow's Hierarchy of Needs Theory should the nurse cluster this data? Love and belonging Self-esteem Self-actualization Safety and security

Safety and security

A client has just fallen out of bed. After ensuring client safety, the nurse completes which of the following? - Safety or Incident report - Malpractice report - Telephone call to hospital's attorney - Progress note stating event report was completed

Safety or Incident report

The planning step of the nursing process includes which of the following activities? - Evaluating goal achievement - Assessing and diagnosing - Setting goals and selecting interventions - Performing nursing interventions and documenting them

Setting goals and selecting interventions

The entity responsible for nurse licensure and enforcing code of conduct is the Nurse Practice Act American Nurses Association (ANA) State Boards of Nursing National League for Nurses

State Boards of Nursing

The type of urinary incontinence in which physical movement or actions cause increased intraabdominal pressure and leakage of urine is Urge incontinence Overflow incontinence Stress incontinence Functional incontinence

Stress incontinence

While conducting a health assessment with an older adult, the nurse notices it takes the person longer to answer questions than is usual with younger clients. What should the nurse do? Talk slowly and allow extra time for answers. Stop asking questions so as not to confuse the client. Realize that the client has some dementia. Ask a family member to answer the questions.

Talk slowly and allow extra time for answers.

The principle of autonomy is demonstrated by a client in which situation? - The family of a client is discussing care with the physician. - A hospice consult is ordered by the nurse. - The client has decided to stop chemotherapy treatments. - An order for an antibiotic is being written in the chart.

The client has decided to stop chemotherapy treatments.

The Glascow Coma Scale (GCS) scores a client on the client's best responses in these categories (select 3 answers) Orientation Appearance Verbal Eye Opening Motor

Verbal Eye Opening Motor

A hypertonic solution contains the same concentration of particles as plasma a minimal amount particles in the solution a greater concentration of particles than plasma a lesser concentration of particles than plasma

a greater concentration of particles than plasma

The nurse is providing care for a 69 year old male client who has been admitted to the hospital for the treatment of pneumonia. Auscultation of the client's lungs reveals the presence of intermittent popping sounds heard during inspiration over the vesicular lung fields. What should the nurse document as being present? stridor crackles wheezes mumur

crackles

An adult client is discharged to home with a prescription for oxygen at a flow rate of 4 L/min. Which oxygen delivery system should the nurse use in this situation? nonrebreather mask nasal cannula simple mask oropharyngeal airway

nasal cannula

The process in which water passes from an area of lesser solute concentration to greater concentration until equilibrium is established - diffusion - capillary filtration - osmosis - selective permeability

osmosis

A client with urine retention related to a complete prostatic obstruction requires a urinary catheter to drain the bladder. Which type of catheter is most appropriate for a client that has an obstructed urethra? suprapubic catheter straight catheter intermittent urethral catheter indwelling urethral catheter

suprapubic catheter