Rn FUND Online Practice 2019 A Wk 10
A nurse enters a clients room and finds them on the floor. The clients roommate reports that the client was trying to get out of bed and fell over the side rail onto the floor. Which of the following statements should the nurse document about this incident?
"Client found lying on floor."
A nurse is caring for a client who has an aggressive form of prostate cancer. The provider briefly discusses treatment options and leaves the client's room. When the nurse asks if the client would like to discuss any concerns, the client declines. Which of the following statements should the nurse make?
"I am available to talk if you should change your mind."
A client who is postoperative is verbalizing pain as a 2 on a pain scale of 0-10. Which of the following statements should the nurse identify as an indication that the client understands the preoperative teaching she received about pain management?
"It might help me to listen to music while I'm lying in bed."
A nurse is talking with an older adult client who is contemplating retirement. The client states, "I keep thinking about how much I enjoy my job. I'm not sure I want to retire." Which of the following responses should the nurse make?
"Let's talk about how the change in your job status will affect you."
A nurse is caring for a client who is scheduled to be transferred to a long term-care facility. The clients family questions the nurse about the reasons to transfer. Which of the following responses made by the nurse is appropriate?
"Would you like it if we discussed the transfer with your family member?"
A nurse is planning an educational program for a group of older adults at a senior living center. Which of the following recommendations should the nurse include?
"You should receive a pneumococcal vaccine when you are 65 years old."
A nurse in a provider's clinic is caring for a client who has heart failure A nurse is evaluating teaching for a client who has heart failure. Which of the following 3 statements by the client indicates an understanding of the teaching?
-"I am limiting my sodium intake to 2 grams daily" -"I am eating fewer potato chips and more fruit for snacks" -"I know to call my doctor if I gain 3 pounds or more in 2 days"
A nurse is preparing to administer 750 mL of 0.9% sodium chloride IV to infuse over 7 hr. The nurse should set the infusion pump to deliver how many mL/hr? (Round to the nearest whole number.)
107 mL/hr
A nurse is caring for a client who has a sodium level of 123 mEq/L. Which of the following findings should the nurse expect?
Abdominal cramping
A nurse is caring for a client who has herpes zoster and asks the nurse about the use of complementary and alternative therapies for pain control. The nurse should inform the client that this condition is a contraindication for which of the following therapies?
Acupuncture
A nurse is providing discharge teaching to a client about self-administering heparin. Which of the following instructions should the nurse include in the teaching?
Administer the medication into the abdomen.
A nurse is preparing to administer enoxaparin subcutaneously to a client. Which of the following actions should the nurse take?
Administer the medication with the needle at a 45* angle.
A nurse is preparing an education program for staff about advocacy. Which of the following information should the nurse include?
Advocacy ensures clients' safety, heath, and rights.
A nurse is assessing a client who received an IV fluid bolus for dehydration. Which of the following findings should the nurse identify as an indication of fluid volume excess?
Distended neck veins
A nurse is admitting a client who has rubella. Which of the following transmission-based precautions should the nurse initiate?
Droplet
A nurse is caring for a client who has pharyngeal diphtheria. Which of the following types of transmission precautions should the nurse use?
Droplet
A nurse is admitting a client who is having an exacerbation of heart failure. In planning the client's care, when should the nurse initiate discharge planning?
During the admission process.
A nurse is admitting a client who is having an exacerbation of heart failure. In planning this clients care, when should the nurse initiate discharge planning?
During the admission process.
A nurse is caring for a client who is receiving pain medication through a patient-controlled analgesia (PCA) pump. Which of the following actions should the nurse take?
Instruct the family to refrain from pushing the button for the client while she is asleep
A nurse is caring for a group of clients. Which of the following actions should the nurse take to prevent the spread of infection?
Place a client who has a tuberculosis in a room with negative-pressure airflow.
A nurse is caring for a client who has a nasogastric (NG) tube and is receiving intermittent feeding through an open system. Which of the following actions should the nurse take FIRST?
Tell the client to keep the head of the bed elevated at least 30°.
A nurse in an emergency department is caring for a client. Complete the following sentence by using the list of options.
The nurse should first REVIEW MEDICATIONS THAT MIGHT BE CAUSING CONFUSIN followed by USING OTHER METHODS TO KEEP CLIENT SAFE
A nurse is caring for a client who has a terminal illness and is approaching death. The client is short of breath and has noisy respirations from secretions in their airway. Which of the following should the nurse take?
Turn the client every 2 hr.
A nurse is caring for a client who has dementia. Which of the following interventions should the nurse take to minimize the risk for injury to the client?
Use a bed exit alarm system.
A nurse is caring for a client who is refusing a blood transfusion for religious reasons. The clients partner wants the client to have the blood transfusion. Which of the following actions should the nurse take?
Withhold the blood transfusion.
A nurse is admitting a client who has been having frequent tonic-clonic seizures. Which of the following actions should the nurse add to the client plan of care?
Wrap blankets around all four sides of the bed.
A nurse in a surgical suite notes documentation on a client's medical record that he has a latex allergy. In preparation for the client's procedure, which of the following precautions should the nurse take?
Wrap monitoring cords with stockinette and tape them in place.
A nurse is caring for a client who has a terminal illness and is at the end of life. The nurse should recognize that which of the following statements by the client's partner indicates effective coping?
"I am relying on support from our family during this time."
A nurse is assessing a clients readiness to learn about insulin self-administration. Which of the following statements should the nurse identify as an indication that the client is ready to learn?
"I can concentrate best in the morning."
A nurse is caring for a client with a diagnosis of terminal cancer. Which of the following statements by the client should indicate to the nurse that the client is ready to hear information regarding palliative care?
"I want you to tell me about measures available to keep me comfortable."
A nurse is providing discharge instructions to a client who will be using a walker. Which of the following statements by the client indicates a need for further instruction by the nurse?
"I will hire someone to trim the tree that hangs low over the stairs of my front porch."
A nurse is caring for a client who reports difficulty falling asleep. Which of the following recommendations should the nurse make?
"Maintain a consistent time to wake up each day."
A middle adult client tells the nurse, "I feel so useless now that my children do not need me anymore." Which of the following responses should the nurse make?
"People in middle adulthood often find satisfaction in nurturing and guiding young people."
A nurse is caring for a client who asks about the purpose of advance directives. Which of the following statements should the nurse make?
"They indicate the form of treatment a client is willing to accept in the event of a serious illness."
A nurse is caring for a client who has a terminal diagnosis and whos health is declining. The client is requesting information about advances directives. Which of the following responses should the nurse make?
"We can talk about advance directives, and I can also give you some brochures about them."
A nurse in a provider's clinic is caring for a client who has heart failure. A nurse is evaluating teaching for a client who has heart failure. Which of the following 3 statements by the client indicates an understanding of the teaching?
-"I am limiting my sodium intake to 2 grams daily" -"I am eating fewer potato chips and more fruit for snacks" -"I know to call my doctor if I gain 3 pounds or more in 2 days"
A nurse is caring for a client who is postoperative. When the nurse prepares to change the clients dressing, they say, "Every time you change my bandage, it hurts so much." Which of the following interventions is the nurses priority action?
Administer pain medication 45 min before changing the client's dressing.
A nurse is planning care of an adolescence who is postoperative following a lumbar laminectomy. Which of the following interventions should the nurse include in the plan of care?
Allow the adolescent to make decisions regarding their daily routine.
A nurse is preparing to delegate client care tasks to an assistive personnel (AP). Which of the following tasks should the nurse delegate?
Ambulating a client who is postoperative
A nurse has just inserted a NG tube for a client. Which of the following findings should the nurse expect to confirm correct tube placement?
An x-ray shows the end of the tube above the pylorus.
A nurse is caring for a client who has a respiratory infection. Which of the following techniques should the nurse use performing nasotracheal suctioning for this client?
Apply intermittent suction when withdrawing the catheter.
A nurse is planning care for a client who has vision loss. Which of the following interventions should the nurse include in the plan of care to assist the client with feeding?
Arrange food in a consistent pattern on the client's plate.
A nurse is preparing to administer an injection of an opioid medication to a client. The nurse draws out 1 mL of the medication from a 2 mL vial. Which of the following actions should the nurse take?
Ask another nurse to observe the medication wastage.
A nurse is caring for a client who is having difficulty breathing. The client is supine and is receiving supplemental oxygen via a nasal cannula. Which of the following interventions should the nurse take first?
Assist the client to an upright position.
A nurse is caring for a client who has an indwelling urinary catheter. Which of the following findings indicates that the catheter requires irrigation?
Bladder scan shows 525 mL of urine.
A nurse receives report about a client who has 0.9% sodium chloride infusing IV at 125 mL/hr. When the nurse performs the initial assessment, he notes that the client has received only 80ml over the last 2 hr. Which of the following actions should the nurse take first?
Check the IV tubing for obstruction.
A nurse is admitting a client who has an abdominal wound with a large amount of purulent drainage. Which of the following types of transmission precautions should the nurse initiate?
Contact precautions
A nurse is administering 1L of 0.9% sodium chloride to a client who is postoperative and has fluid-volume deficit. Which of the following changes should the nurse identify as an indication that the treatment was successful?
Decrease in heart rate
A nurse is assessing four adult clients. Which of the following physical assessment techniques should the nurse use?
Ensure the bladder of the blood pressure cuff surrounds 80% of the client's arm.
A client who is nonambulatory notifies the nurse that his trash can is on fire. After the nurse confirms the fire, which of the following actions should the nurse take next?
Evacuate the client.
A nurse is caring for a child who has a prescription for a blood transfusion. The child's parents have refused the treatment due to their religious beliefs. Which of the following actions should the nurse take?
Examine personal values about the issue.
A charge nurse is discussing the responsibility of nurses caring for clients who have a clostridium difficle infection. Which of the following information should the nurse include in the teaching?
Have family members wear a gown and gloves when visiting.
A nurse is caring for a client who requires an NG tube for stomach decompression. Which of the following actions should the nurse take when inserting the NG tube?
Have the client take sips of water to promote insertion of the NG tube into the esophagus.
A nurse is caring for a client who has limited mobility in their lower extremities. Which of the following actions should the nurse take to prevent skin breakdown?
Have the client use a trapeze bar when changing position.
A nurse is initiating a protective environment for a client who has an allogenic stem cell transplant. Which of the following precautions should the nurse plan for this client?
Make sure the client wears a mask when outside their room if there is construction in the area.
A nurse is caring for a client who is postoperative following a knee arthroplasty and requires the use oh thigh-length sequential compression sleeves. Which of the following actions should the nurse take?
Make sure two fingers can fit under the sleeves.
A nurse is caring for a client who is postoperative and is exhibiting signs of hemorrhagic shock. The nurse notifies the surgeon, who tells the nurse to continue to measure the clients vital signs every 15 min and to report back in 1 hr. Which of the following actions should the nurse take?
Notify the nursing manager.
A nurse is on a medical-surgical unit is caring for a client who has a new prescription for wrist restraints. Which of the following actions should the nurse take?
Pad the client's wrist before applying the restraints.
A nurse is planning to insert a peripheral IV catheter for an older adult client. Which of the following actions should the nurse plan to take?
Place the client's arm in a dependent position.
A nurse us reviewing a clients fluid and electrolyte status. Which of the following findings should the nurse report to the provider?
Potassium 5.4 mEq/L
A nurse is administering an otic medication to an older adult client.. Which of the following actions should the nurse take to ensure that the medication reaches the inner ear?
Press gently on the tragus of the client's ear.
A nurse is completing an admission assessment for a client who reports vomiting and diarrhea for the past 3 days. Which of the following finding should the nurse except?
Rapid heart rate
A nurse is caring for a client who is expressing anger about his diagnosis of colorectal cancer. Which of the following actions should the nurse take?
Reassure the client that this is an expected response to grief.
A nurse is reviewing evidence-based practice principles about administration of oxygen therapy with a newly licensed nurse. Which of the following actions should the nurse include?
Regulate oxygen via nasal cannula at a flow rate of no more than 6 L/min.
A nurse is talking with the partner of a client who has dementia. The clients partner expresses frustration about finding time to manage household responsibilities while caring for their partner. The nurse should identify that the partner is experiencing which of the following types of role-performance stress?
Role overload
A nurse is preparing a change-of-shift report. Which of the following tools or documents should the nurse use to communicate continuity of care?
Situation, background, assessment, and recommendation (SBAR)
A nurse is lifting a bedside cabinet to move it closer to a client who is sitting in a chair. To prevent self-injury, which of the following actions should the nurse take when lifting this object?
Stand close to the cabinet when lifting it.
A nurse is using an open irrigation technique to irrigate a clients indwelling catheter. Which of the following actions should the nurse take?
Subtract the amount of irrigatant used from the client's urine output.
A nurse is evaluating a clients use of a cane. Which of the following actions should the nurse identify as an indication of correct use?
The client holds the cane on the stronger side of her body.
A home health nurse is performing a follow-up visit for a client who has a gastrostomy tube through which they receive intermittent feedings and medications. The client has recently developed diarrhea. Which of the following findings should the nurse identify as a possible cause of the diarrhea?
The client's caregiver washes out the feeding bag with warm water once every 24 hr.
A nurse is caring for a client who has a new diagnosis for seizure disorder. Complete the following sentence by using the list of options.
The nurse should first address the client's PRIVACY followed by the client's POSITIONING.
A nurse is caring for a client who has diarrhea due to shigella. Which of the following precautions should the nurse implement for this client?
Wear a gown when caring for the client.
A nurse in a provider's office is assessing the deep tendon reflexes of a client. Which of the following images should the nurse identify as indicating the correct technique for eliciting the client's patellar reflex?
image with the device being used on the front of the knee
A nurse is educating a client who has a terminal illness about declining resuscitation in a living will. The client asks, "What would happen if I arrived at the emergency department and I had difficulty breathing?" Which of the following responses should the nurse make?
"We would give you oxygen through a tube in your nose."
A nurse is performing a skin assessment for a client who expresses concern about skin cancer. Which of the following findings should the nurse identify as a potential indication of a skin malignancy?
A mole with an asymmetrical appearance.
A nurse is assessing a client who has required bed rest for the past month. Which of the following findings should the nurse identify as an indication that the client has developed thrombophlebitis?
Calf swelling
A nurse is responding to a call light and finds a client lying on the bathroom floor. Which of the following actions should the nurse take first?
Check the client for injuries.
A nurse is auscultating the anterior chest of a client who was newly admitted to medical-surgical unit, Listen to the audio clip of what the nurse auscultates through the stethoscope and identify the type of breath sounds. (Click on the audio button to listen to the clip.)
Normal breath sounds
A nurse is discussing the use of herbal supplements for health promotion with a client. Which of the following client statements indicates an understanding of herbal supplement use?
"I can take echinacea to improve my immune system."
A nurse is caring for a client who requires 24-hr urine collection. Which of the following statements by the client indicates an understand of the teaching?
"I flushed what I urinated at 7:00 a.m. and have saved all urine since."
A nurse is caring for a client who is postoperative following abdominal surgery. Click to highlight the assessment findings below that the nurse should report to the provider. To deselect a finding, click on the finding again.
-Urinary output -Reported pain level -Vital signs
A nurse is assessing a client who reports increased pain following physical therapy. Which of the following questions should the nurse ask when assessing the quality of the clients pain?
"Is your pain sharp or dull?"
A nurse manager is preparing to review medication documentation with a group of newly licensed nurses. Which of the following statements should the nurse manager plan to include in the teaching?
"Use the complete name of the medication magnesium sulfate."
A nurse is caring for a client in a medical-surgical unit. After reviewing the assessment findings. which of the following actions should the nurse plan to take? Select the 3 actions that the nurse should plan to take.
-Administer analgesic prior to planned activities. -Delegate the application of sequential compression devices to assistive personnel.term-29 -Assist the client to dangle their legs a the bedside prior to standing.
A nurse is planning care for a client who has had a stroke, resulting in aphasia and dysphagia. Which of the following tasks should the nurse assign to an assistive personnel (AP)?
-Assist the client with a partial bed bath. -Measure the client's BP after the nurse administers an antihypertensive medication. -Use a communication board to ask what the client wants for lunch.
A nurse in the emergency department (ED) is caring for a client. Click to highlight the findings that indicate the client is malnourished. To deselect a finding, click on the finding again.
-Cachectic, with flaccid muscle tone. -Skin dry and scaly with bruises on extremities. -Pulse rate 118/min -Abdomen distended -BMI 17
A nurse in a provider's clinic is caring for a client who has diarrhea. The nurse is providing teaching for the client who has diarrhea. Select the 4 instructions that the nurse should include in the teaching.
-Eat probiotic foods, such as yogurt. -Avoid alcohol while experiencing diarrhea. -Avoid caffeine while experiencing diarrhea. -Follow a low-fiber diet.
A nurse in a long-term care facility is caring for a client who dies during the nurse's shift. Identify the sequence in which the nurse should perform the following steps.
-Obtain the death pronouncement from the provider. -Remove tubes and indwelling lines. -Wash the clients body. -Ask the clients family members if they'd like to view the body. -Place a name tag on the body.
A nurse4 is caring for a client who has tuberculosis. Which of the following actions should the nurse take? (Select all that apply?
-Place the client in a room with negative-pressure airflow. -Wear gloves when assisting the client with oral care. -Use antimicrobial sanitizer for hand hygiene.
A nurse is admitting a client. The nurse is reviewing the clients medical record. Which of the following actions should the nurse take? SELECT ALL THAT APPLY.
-Place the client on droplet isolation precautions. -Apply oxygen at 2 L/min via nasal cannula. -Request a prescription for an antipyretic medication. -Remain 1 m (3 feet) from the client.
A nurse is assessing an older adult client's risk for falls. Which of the following assessments should the nurse use to identify the client's safety needs? (Select all that apply.)
-Pupil clarity -Visual fields -Visual acuity
A nurse us caring for a client who has a pressure injury. Click to highlight the findings that the nurse should report to the provider. To deselect a finding, click on the finding again.
-Temperature -WBC count -Prealbumin level -Pain level- Odor of wound
A nurse is admitting a new client. Which of he following actins should the nurse take while performing medication reconciliation?
Compare the client's home medications with the provider's prescriptions.
A nurse is caring for a client who is postoperative and refuses to use an incentive spirometer following major abdominal surgery. Which of the following actions in the nurse's priority?
Determine the reasons why the client is refusing to use the incentive spirometer.
A nurse us preparing to apply a dressing for a client who has a stage 2 pressure injury. Which of the following types of dressing should the nurse use?
Hydrocolloid
A nurse is planning strategies to mange time effectively for client care. Which of the following strategies should the nurse implement?
Use the planning step of the nursing process to prioritize client care delivery.
A nurse is teaching a client and his family how to care for the clients tracheostomy at home. Which of the following instructions should the nurse include in the teaching?
Use tracheostomy covers when outdoors.
