pn fundamentals online practice 2020 B

Complete the following sentence by using the lists of options. The nurse should first address the __________, followed by the _________.

1. color of the stoma 2. skin condition around the stoma

A nurse is providing oral hygiene for a client who is unconscious. Identify the sequence of the steps the nurse should take. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)

1. Assess the client's gag reflex is the first step. 2. Position the client on their side with their head turned to the side is the second step. 3. Place a towel under the client's head with an emesis basin under their chin is the third step. 4. Separate the client's upper and lower teeth with an oral airway device is the fourth step 5. Cleanse the client's mouth using a toothbrush is the fifth step.

A nurse is caring for a client who is scheduled for surgery the following day. During the night, the client is unable to sleep and is restless. Which of the following statements should the nurse make? A. "It must be difficult facing this type of surgery." B. "Other clients who have had this surgery have done just fine." C. "This facility is known for providing excellent care for people who need this type of surgery." D. "I can request a sleeping pill, if you think that will help."

A. "It must be difficult facing this type of surgery." Stating that it must be difficult to be in this position is an open-ended and nonjudgmental statement that allows the client to talk about their fears.

A nurse is caring for a client who reports difficulty sleeping at home. Which of the following recommendations should the nurse provide to promote a restful home sleep environment? A. "Perform muscle relaxation before bedtime." B. "Exercise vigorously 1 hour prior to going to bed." C. "Drink a cup of hot chocolate at bedtime." D. "Change the time you go to sleep each day."

A. "Perform muscle relaxation before bedtime." The nurse should encourage the client to perform muscle relaxation to reduce anxiety and induce sleep.

A nurse is preparing a client for a Romberg test. Which of the following statements should the nurse make? A. "Stand with your feet together and your arms at your sides." B. "After I place the tuning fork, tell me when you no longer hear the sound." C. "I'm going to stroke the lateral side of the bottom of your foot." D. "Touch each fingertip as quickly as possible with your thumb."

A. "Stand with your feet together and your arms at your sides." The Romberg test measures stability with and without the eyes closed. The nurse should instruct the client to stand with their feet together and their arms at their sides.

A nurse is caring for a client who has an indwelling urinary catheter. Which of the following actions should the nurse take? A. Clean the perineal area at least once a day. B. Empty the drainage bag when it is three-fourths full. C. Flush the catheter with sterile water daily. D. Disconnect the drainage bag when emptying and measuring urine.

A. Clean the perineal area at least once a day. The nurse should clean the perineal area at least once a day to reduce the risk for infection.

Select the 3 tasks the nurse should delegate to an assistive personnel (AP). A. Document the client's vital signs. B. Measure the client's intake and output. C. Collect data about the client's pain level. D. Insert an NG tube for the client. E. Transfer the client from a wheelchair to the bed.

A. Document the client's vital signs is correct. The nurse should identify that documenting the client's vital signs is a task that is within an AP's range of function. B. Measure the client's intake and output is correct. The nurse should identify that measuring the client's intake and output is a task that is within an AP's range of function. E. Transfer the client from a wheelchair to the bed is correct. The nurse should identify that transferring the client from a wheelchair to the bed is a task that is within an AP's range of function.

A nurse is caring for a client who has limited mobility. Which of the following actions should the nurse take to maintain the client's skin integrity? A. Use warm water when bathing the client. B. Place a donut-shaped cushion in the client's chair. C. Massage reddened areas over bony prominences. D. Maintain the client in high-Fowler's position.

A. Use warm water when bathing the client. The nurse should use warm water to bathe the client because hot water can dry and damage the skin.

The nurse is evaluating the client's understanding of the teaching. Select the 3 client statements that indicate an understanding of the teaching. A. "I have been weighing myself twice a week." B. "I am limiting my sodium intake to 2 grams daily." C. "I am trying to decrease my intake of foods with potassium." D. "I am eating fewer potato chips and more fruit for snacks." E. "I know to call my doctor if I gain 3 pounds or more in 2 days."

B. "I am limiting my sodium intake to 2 grams daily." D. "I am eating fewer potato chips and more fruit for snacks." E. "I know to call my doctor if I gain 3 pounds or more in 2 days."

A nurse is providing care to four clients in an acute care setting. The nurse should identify that which of the following client statements presents an ethical dilemma? A. "I might file a lawsuit because of how my surgery went." B. "Please don't tell my doctor, but I am taking my partner's oxycodone." C. "Please don't get me out of bed this morning. It hurts too much." D. "I don't want to take my medicine. It makes me sick to my stomach."

B. "Please don't tell my doctor, but I am taking my partner's oxycodone." This situation poses an ethical dilemma for the nurse because there is a conflict between what the client is asking of the nurse and the nurse's responsibility to protect the client from harm during hospitalization.

A nurse is reinforcing teaching with the partner of a client who is immobile. Which of the following instructions should the nurse give the partner about turning the client in bed? A. "Keep your feet close together." B. "Tighten your stomach muscles." C. "Straighten your knees." D. "Bend at your waist."

B. "Tighten your stomach muscles." The nurse should instruct the client's partner to tighten the abdominal and gluteal muscles to help protect their back.

A nurse is caring for a client who reports itching 30 min after receiving a newly prescribed medication. Which of the following data should the nurse document in the client's medical record? A. Client is itching from medication. B. Client states, "I started to itch after taking that medication." C. It appears that the client has a rash from the medication. D. Rash from medication noted.

B. Client states, "I started to itch after taking that medication." The nurse should document information using an objective description, putting the client's exact words in quotation marks.

A nurse is planning care for a group of clients. The nurse should expect to witness an informed consent for a client who will undergo which of the following procedures? A. Administration of an enema B. Performance of a paracentesis C. Insertion of an indwelling urinary catheter D. Placement of an NG tube

B. Performance of a paracentesis The nurse should expect to witness the informed consent for a client prior to an invasive diagnostic procedure, such as a paracentesis.

A nurse is evaluating the crutch-walking technique of a client who is required to keep weight off their right leg. Which of the following is the proper crutch gait for this client? A. Four-point B. Three-point C. Two-point D. Swing-through

B. Three-point The nurse should identify that the client needs to be able to bear weight on the unaffected leg; therefore, a three-point gait provides at least two points of support at all times.

A nurse is contributing to the plan of care for a client who practices Islam. Which of the following questions should the nurse ask the client to clarify the client's religious preferences? A. "Do you receive Holy Communion?" B. "Do you follow a kosher diet?" C. "Do you consume pork products?" D. "Do you oppose receiving a blood transfusion if it is needed?"

C. "Do you consume pork products?" Some clients who practice Islam do not consume pork or alcohol.

A nurse is preparing to document information about a client's lower legs, which are swollen with 6 mm edema. Which of the following information should the nurse document? A. 1+ pitting edema B. 2+ pitting edema C. 3+ pitting edema D. 4+ pitting edema

C. 3+ pitting edema The nurse should document 3+ pitting edema when there is deep indentation of the tissue, which is about 6 mm.

A nurse manager is reinforcing teaching with a group of newly licensed nurses about the disclosure of client health information. A nurse can disclose health information without the client's written permission to which of the following entities? A. An insurance agency offering a life insurance policy B. A family member who requests the client's diagnosis C. A physical therapist who is involved in the client's care D. An employer completing a pre-employment screening

C. A physical therapist who is involved in the client's care According to HIPAA guidelines, a nurse is allowed to disclose personal health information to members of the health care team involved in the client's care.

A nurse is collecting data from a client following a lumbar puncture. The nurse should identify which of the following findings as a potential adverse effect of this procedure? A. Fluid overload B. Diarrhea C. Headache D. Difficulty voiding

C. Headache The nurse should identify that a headache can be an adverse effect following a lumbar puncture. To minimize the client's discomfort, the nurse should administer analgesics, offer fluids, and maintain the client in a dorsal recumbent position for the length of time prescribed by the provider.

Click to highlight the findings that indicate the client might be malnourished. To deselect a finding, click on the finding again. A nurse in an emergency department (ED) is assisting in the care of a client. Nurses Notes 1100:Client arrives to ED with report of nausea, vomiting, and diarrhea for 3 days. Client is febrile.1110:Provider at bedside; prescriptions received.1115:IV initiated in right arm with 20-gauge catheter. Acetaminophen and metoclopramide administered.1200:Client appears fatigued with no energy. Hair is thin and sparse. Client is cachectic with flaccid muscle tone. Oriented to person, place, and time. Client is able to move all extremities. Tachycardia and edema to lower extremities present. Respirations are unlabored, and lung sounds are clear. Bowel sounds in all four quadrants are hyperactive, and abdomen is distended. Reports no difficulty with urination. Skin is dry and scaly with bruises on extremities.

Client is cachectic with flaccid muscle tone is correct. Skin is dry and scaly with bruises on extremities is correct. Pulse rate 118/min is correct. Abdomen is distended is correct BMI 17 is correct

A nurse is caring for four clients. For which of the following clients should the nurse use the therapeutic communication technique of silence? A. A client who plans to leave the facility against medical advice B. A client who informs the nurse that they have made their funeral arrangements C. A client who tells the nurse that the night shift nurse did not bring their medication D. A client who has just experienced the death of their child

D. A client who has just experienced the death of their child Silence is a therapeutic communication technique to use when a client is grieving. It demonstrates caring and patience and allows the client to speak when they are ready to do so.

A nurse is preparing to remove staples from a client's incision. Which of the following actions should the nurse take? A. Lift the staple remover when squeezing the handle. B. Avoid completely closing the handle after squeezing. C. Expect the staples to bend at each outer side of the staple. D. Remove the staple from the skin after both sides are visible.

D. Remove the staple from the skin after both sides are visible. The nurse should remove the staple from the skin after both sides of the staple are visible, which indicates proper dislodgement of the staple and prevents pulling on the skin around the incision, which can cause needless discomfort.

Click to highlight the findings below that that require intervention by the nurse. To deselect a finding, click on the finding again. A nurse is caring for a client who had a spinal cord injury and has paraplegia.

Passive range-of-motion exercises to lower extremities performed once daily is correct. Plantar flexion contractures noted bilaterally is correct. Left heel has 1.3 cm x 1.3 cm (0.5 in x 0.5 in) area of nonblanchable erythema; skin is intact is correct.

The nurse is reviewing the client's medical record. Which of the following actions should the nurse take? Select all that apply. Nurses Notes 0930:Client reports a sore throat, productive cough, shortness of breath, and fever for the past 4 days.1030:Client has swollen cervical lymph nodes on palpation. Client reports chills and coughs up yellow-colored mucus. Client's face is flushed and is diaphoretic. Reports poor appetite. Chest x-ray obtained and positive for pneumonia.

Place the client in droplet isolation precautions is correct. Apply oxygen at 2 L/min via nasal cannula is correct. Request a prescription for an antipyretic medication is correct Stay at least 0.9 m (3 feet) away from the client when possible is correct

A nurse is collecting data from the client. Which of the following actions should the nurse take? Select all that apply. A nurse is caring for a client who has a peripheral IV inserted for fluid replacement.

Stop the IV infusion is correct. Elevate the client's left arm is correct. Apply heat to the client's left hand is correct.