Saunders Fundamentals

The nurse is reinforcing diet teaching for a client on a low-sodium diet for hypertension. The nurse determines that there is a need for further teaching when the client makes which statement?

"Canned foods are inexpensive and are good to use on a low-sodium diet."

The nurse is assisting in providing surgical instructions to a preoperative client who will have abdominal surgery. Which instructions would be appropriate to include in the preoperative plan of care? Select all that apply.

Frequent assessment of vital signs Coughing and deep breathing exercises Pain monitoring and medications to relieve pain

The nurse will perform a sterile dressing change after removing the old dressing with clean gloves. The nurse removes the gloves, uses alcohol-based hand sanitizer to perform hand hygiene, and prepares to perform open sterile gloving. The nurse removes the gloves from the outer package. The nurse is right-handed. The nurse opens the inner wrapper and flattens the wrapper to expose the gloves. Which is the next action the nurse takes when donning sterile gloves

Pick up right glove at cuff with left thumb and forefinger.

A client who has open draining lesions from Kaposi's sarcoma needs to be bathed and have bed linens changed. Which should the nurse wear to perform these tasks?

Gown and gloves

A client arrives at the clinic complaining of a severe headache. The client states "It's a 10/10 headache. I took 600 mg of ibuprofen over the past few hours, and it has not decreased the pain." The nurse suspects that the client is experiencing a migraine but wants to validate the suspicion by asking which questions associated with a migraine? Select all that apply.

"Can you describe the pain?" "What other symptoms are you experiencing?" "What did you experience right before the headache began?" "Do you or a family member have a history of severe headaches?"

The nurse is providing instructions to the mother of a toddler regarding safety measures in the home to prevent an accidental burn injury. Which statement by the mother indicates a need for further teaching?

"I need to be sure to place my cup of coffee on the counter."

The nurse is reinforcing instructions to a female client regarding the procedure for collecting a midstream urine sample. Which statement by the client indicates an understanding of the procedure?

"I need to collect the urine in the cup after I start to urinate."

The client has just undergone computed tomography (CT) scanning with a contrast medium. Which statement by the client demonstrates an understanding of postprocedure care?

"I should drink extra fluids for the remainder of the day."

A client with sickle cell anemia is being treated for sickle cell crisis. The primary health care provider prescribes morphine sulfate 2 mg. The concentration of the vial is 10 mg/mL of solution. How many milliliters of solution should the nurse administer? Fill in the blank. Record the answer to one decimal place.

0.2 ml

The nurse is preparing to administer 30 mEq of liquid potassium chloride (KCl) to an adult client. The label on the medication bottle reads 40 mEq/15 mL. The nurse prepares how many milliliters of KCl to administer the correct dose of medication? Fill in the blank. Round your answer to the nearest whole number.

11 ml

A client has been admitted to the hospital for urinary tract infection and dehydration. The nurse determines that the client has received adequate volume replacement if the blood urea nitrogen level drops to which value?

15 mg/dL (5.25 mmol/L)

A licensed practical nurse (LPN) is asked to prepare an intravenous (IV) infusion of 1000 mL 5% dextrose in lactated Ringer's at 80 mL/hr to be administered to an assigned client. The LPN time-tapes the bag with a start time of 09:00. After making hourly marks on the time-tape, the LPN notes that which time would mark the completion time for the bag?

2130

A primary health care provider prescribes phenobarbital, 10 mg by mouth daily. The medication bottle is labeled 15 mg/5 mL. How many milliliters (mL) will the nurse administer? Fill in the blank. Record your answer using one decimal place.

3.3 ml

The client is to receive a soapsuds enema. Which is the best position for administering an enema? Refer to figure.

A lying on side with top leg bent

The nurse is monitoring an adult client for postoperative complications. Which is most indicative of a potential postoperative complication that requires further observation?

A urinary output of 20 mL/hour

A client's arterial blood gases reveal a pH of 7.51 and a bicarbonate level of 31 mEq/L. The nurse prepares for the administration of which medication that should be prescribed to treat this acid-base disorder?

Acetazolamide

The nurse is preparing to comb the hair of a child client who has been treated for pediculosis (lice) at a clinic. Which additional instructions should the nurse give the parents of the child? Select all that apply.

All head wear and bed linens should be washed in hot water. A parent should observe all persons in the household for presence of lice or nits If others in the household are found to have pediculosis, they all must be treated and have the nits removed from their hair.

The nurse, employed in a long-term care facility, is planning the clinical assignments for the day. The nurse knows not to assign which staff member to the client with a diagnosis of herpes zoster?

An unlicensed assistive personnel who has never had chickenpox

A postoperative client has been placed on a clear liquid diet. Which items is the client allowed to consume? Select all that apply.

Broth Coffee Gelatin

The nurse determines that which herbal therapies can be prescribed for use as an antispasmodic? Select all that apply.

Chamomile Peppermint oil

While caring for a client admitted to the hospital with suspected seizure activity, the client acknowledges the use of the herbal supplement ginkgo, to the nurse. Which follow-up questions by the nurse would be most appropriate? Select all that apply.

Do you have a history of seizures? Do you have a history of a clotting disorder? How long and why have you been using ginkgo? Have you been diagnosed with diabetes mellitus?

A postoperative client has been receiving morphine sulfate every 3 to 4 hours for pain. The nurse should be sure to implement which measures to reduce the risk of adverse effects from this medication? Select all that apply.

Encourage fluids when not NPO. Encourage coughing and deep breathing. Monitor the number of bowel movements.

A client has the following laboratory values: pH of 7.55, HCO3- of 22 mm Hg, and a Pco2 of 30 mm Hg. Which action should the nurse take?

Encourage the client to slow down his breathing.

The nurse is assisting in the care of a client with a new ileostomy on the clinical nursing unit. Which observations indicate to the nurse that the client is at risk for fluid volume deficit? Select all that apply.

Ileostomy output of 650 mL in 4 hours Blood pressure (BP) 104/66 mmHg, temperature 98.4° F, pulse 106 beats per minute, respirations 20 breaths per minute

The nurse is caring for a client with a diagnosis of hyperparathyroidism. Laboratory studies are performed and the serum calcium level is 12.0 mg/dL (3.0 mmol/L). Based on this laboratory value, the nurse should take which action?

Inform the registered nurse of the laboratory value.

The nurse is preparing to administer an acetaminophen suppository to a child. The nurse plans which action?

Insert the suppository 1 to 2 cm into the rectum.

The nurse has reinforced postprocedure instructions to a client who has undergone a colonoscopy. The nurse determines that there is a need for further teaching if the client makes which statement?

It is all right to drive an hour after the test is finished.

The nurse is assisting in the care of a client with a left foot that sustained a crush injury. The nurse determines that the client developed third spacing of body fluid based on which observation?

Left foot has 4+ pitting edema.

A client presents to the emergency department with lethargy; deep, regular respirations; and a fruity odor to the breath. The client's arterial blood gas (ABG) results are pH of 7.25, Pco2 of 34 mm Hg, Po2 of 86 mm Hg, and HCO3- of 14 mEq/L. The nurse interprets that the client has which acid-base disturbance?

Metabolic acidosis

A client with diabetes mellitus has a blood glucose level of 596 mg/dL on admission. The nurse anticipates that this client is at risk for which type of acid-base imbalance?

Metabolic acidosis

The nurse is caring for a client with a nasogastric tube that is attached to low suction. The nurse monitors the client closely for which acid-base disorder that is most likely to occur in this situation?

Metabolic alkalosis

The nurse is preparing to set up a sterile field using the principles of aseptic technique to perform a dressing change. Which should the nurse include in the preparations? Select all that apply.

Open the distal flap of a sterile package first. Prepare the sterile field just before the planned procedure. Avoid placing items within 1 inch of any area surrounding the outer edge of the sterile field.

The nurse is reviewing the laboratory results from the lumbar puncture performed on a client with a diagnosis of meningitis. Which findings are indicative of a bacterial infection? Select all that apply.

Protein level of 20 mg/dL Increased white blood cells A cerebrospinal fluid (CSF) pressure of 250 mm H2O

A client has a prescription to have radial arterial blood gases (ABGs) drawn. Before drawing the sample, an Allen's test will be performed. In performing the Allen's test, which blood vessel(s) should the nurse occlude?

Radial and ulnar arteries, releases one, evaluates the color of the hand, and repeats the process with the other artery

The nurse is preparing a client for a magnetic resonance imaging (MRI) examination. Which action by the nurse is important?

Remove metallic objects from the client.

A client is admitted to the surgical unit postoperatively with a self-suction Jackson-Pratt wound drain in place. The nurse determines the drain is functioning correctly with which observations? Select all that apply.

The bulb container is fully compressed. Bright red bloody drainage is present in the bulb container.

A client suspected of having an abdominal tumor is scheduled for a computed tomography (CT) scan with dye injection. The nurse should tell the client which information about the test?

The dye injected may cause a warm, flushing sensation.

The nurse is assisting a client to ambulate when the client states he is feeling faint and cannot stand. Which action should the nurse take to assist the client now?

The nurse should extend one leg to use to slide the client's body down to the floor.

The nurse reviews a client's electrolyte results and notes a potassium level of 5.5 mEq/L (5.5 mmol/L). The nurse understands that a potassium value at this level would be noted with which condition?

Traumatic Burn

A client is seen in the urgent care center for complaints of chest pain 2 days ago. Since that time, the client has not been feeling well and fatigues easily. The nurse reviews the results of the laboratory tests. An elevation of which laboratory test indicates a myocardial infarction occurred at the time of chest pain 2 days ago?

Troponin I

Which cardiovascular sign should the nurse expect to note in a client with a diagnosis of hypocalcemia?

hypotension

Which arterial blood gas (ABG) result should the nurse anticipate in the client who develops metabolic alkalosis after profuse vomiting for 2 days?

pH 7.49; Pco2 45; HCO3- 30

The nurse is planning to feed an older client who is at risk for aspiration of food. During the meal how should the nurse position the client?

Upright in a chair

The nurse is assisting in the care of a client who has a serum sodium level of 128 mEq/L (128 mmol/L). The nurse relates which of the client's signs and symptoms to this electrolyte imbalance? Select all that apply.

Weakness in all extremities Confusion with garbled speech Diarrhea with abdominal cramping

Which statement made by the nursing student indicates a need for further teaching by the nursing instructor on the concept of ethnocentrism?

"It is imposing one's beliefs on individuals from another culture."

The nurse is caring for a client at risk for postpartum endometritis. Which nursing intervention would minimize this risk following delivery?

Reviewing hand-washing techniques and pericare with the client

The nurse is performing an environmental assessment in the home of an older client. Which observations require immediate attention? Select all that apply.

Unsecured scatter rugs Cigarette pack and lighter on the bedside stand

A client has been diagnosed with metabolic alkalosis. Which laboratory values are most important for the nurse to monitor for this client? Select all that apply.

Serum electrolytes Arterial blood gases (ABGs)

Intravenous (IV) lactated Ringer's (LR) solution is prescribed for a postoperative abdominal surgery client. A nursing student is caring for the client, and the nursing instructor asks the student about why this IV solution is prescribed. Which student response is correct?

"LR is isotonic to plasma and contains electrolytes"

A client is diagnosed with cancer and is told that surgery followed by chemotherapy will be necessary. The client states to the nurse, "I have read a lot about complementary therapies. Do you think I should try any?" The nurse should respond by making which appropriate statement?

"Tell me what you know about complementary therapies."

Abdominal ultrasonography is prescribed for a client who is pregnant. The nurse provides information to the client regarding the procedure and makes which statement?

"You will be positioned on your back and turned slightly to one side with your head elevated."

A client is receiving an enteral feeding that delivers 1.5 calories/mL. The feeding is infusing at 30 mL/hr via a feeding pump. What is the maximal amount of calories the client should receive in an 8-hour period if the tube feeding is not interrupted? Fill in the blank.

360 calories

A client who takes theophylline for chronic obstructive pulmonary disease (COPD) is seen in the urgent care center for respiratory distress. Just before initiating treatment for the respiratory distress, a sample for a theophylline level is drawn. The nurse notes the therapeutic range for the serum theophylline level is 10 to 20 mcg/mL and determines that the client may not be taking the medication as prescribed if which result is obtained?

6 mcg/mL

The nurse reinforces teaching a client on how to administer enoxaparin subcutaneously. The nurse determines that the client understands the correct procedure if the client does which on a return demonstration?

Bunches the skin before injection

After having a transurethral resection of the prostate (TURP), a client has a continuous bladder irrigation (CBI) postoperatively. The nurse notes that fluid is entering the bladder, but none appears to be draining. Select the appropriate nursing interventions. Select all that apply.

Check the bladder for distention. Review intake and output record. Check to ensure drainage tubing is not kinked. Ask the client about bladder spasms and discomfort.

The nurse is changing the abdominal dressing on a client following a suprapubic prostatectomy. A wound drain is in place in the abdominal wound. Which nursing action would be appropriate during the dressing change?

Checking the wound site for drainage from the drain

An abdominal postoperative client has been tolerating a full liquid diet, and the nurse plans to advance the diet to solid food as prescribed. The nurse collects data regarding which important item before advancing the diet to solids?

Dentition and ability to chew

The nurse is working in a long-term care facility and is observing a new unlicensed assistive personnel (UAP) caring for a client who requires a security device (wrist restraints). The nurse determines that the UAP is providing safe care if the nurse observes the UAP checking skin integrity by completely removing the client's wrist restraints at which time interval?

Every 2 hours

An adolescent client is admitted to the hospital following an accidental gunshot wound to the foot. The nurse should plan to do which as a first step for the prevention of future injury?

Explore the adolescent's knowledge of gun safety.

The nurse working the 3:00 to 11:00 pm shift notes that a client with coronary artery disease (CAD) has a prescription for serum lipid levels to be drawn in the morning. The nurse places the client on which dietary preparation to ensure accurate test results?

Fasting for 12 hours

The nurse is assigned to assist in caring for a client who is receiving parenteral nutrition with fat emulsion. The nurse is instructed to monitor the client for signs of fat overload. The nurse monitors for which signs and symptoms of this complication?

Fever and pruritic urticaria

A client who has recently been started on enteral feedings begins to complain of abdominal cramping, followed by passage of two liquid stools. The nurse notes that the client has abdominal distention as well. The nurse reviews the nutritional content on the label of the can to see if it contains which ingredient?

Lactose

A newly pregnant client is asking how to prevent neural-tube birth defects. The nurse reinforces which food choices to include in the diet? Select all that apply.

Oranges Broccoli Grapefruit

The nurse has conducted dietary teaching with the client diagnosed with iron deficiency anemia. The nurse determines that the client understands the information if the client states the intention to increase intake of which foods? Select all that apply.

Oysters Spinach Kidney beans

The nurse is caring for a client who has a wound infection. Contact precautions are being followed. Which are correct actions by the nurse when using personal protective equipment (PPE)? Select all that apply.

Perform hand hygiene after removal of PPE. Perform hand hygiene before donning any PPE. When removing PPE, always remove gloves first. Protective eyewear and face shield are indicated if there is risk of splatter.

Several laboratory tests are prescribed for a client, and the nurse reviews the results of the tests. Which laboratory test results should the nurse report? Select all that apply.

Platelets 35,000 mm3 (35 × 109/L) Sodium 150 mEq/L (150 mmol/L) Segmented neutrophils 40% (0.40) White blood cells, 3000 mm3 (3.0 × 109/L)

A client is at risk for developing hypocalcemia. The nurse determines which signs are associated with this electrolyte disturbance? Select all that apply.

Positive Trousseau's sign Fine tremors noted in hands

A client is recovering from abdominal surgery and has a large abdominal wound. The nurse encourages the client to eat foods from which nutrient categories to promote wound healing? Select all that apply.

Protein Vitamin C

The nurse is working with an unlicensed assistive personnel (UAP) to care for clients. While observing the UAP's delivery of care, the nurse notes which actions by the UAP that indicates the need for further teaching regarding standard precautions? Select all that apply.

Removes gloves and immediately uses computer to document care Uses soap and water to wash hands for 5 seconds and then dries hands Empties collection bag of an indwelling urinary catheter without wearing gloves

The nurse is assisting to admit a client with a diagnosis of acute Guillain-Barré syndrome. The nurse knows that if the disease progresses to a severe level, the client will be at risk for which acid-base imbalance?

Respiratory acidosis

A client has a serum sodium level of 151 mEq/L (151 mmol/L), and the nurse reinforces dietary teaching about the types of foods to avoid. The nurse determines that there is a need for further teaching if the client states that which food choices are good? Select all that apply.

Sauerkraut American Cheese

A client has been diagnosed with functional incontinence. Which interventions are most appropriate to care for this type of incontinence? Select all that apply.

Schedule toileting every 2 hours. Modify clothing for easy removal. Assess environment for obstacles. Set up schedule of cues such as mealtimes, awakening, and bedtime.

The nurse is caring for a postoperative client who is wearing an abdominal binder following abdominal surgery. Which interventions should the nurse include in relationship to prescribed dressing change? Select all that apply.

Sit up for coughing while splinting the incision. Remove the binder to change the abdominal dressing as prescribed and reapply.

The nurse, caring for a client with a postoperative abdominal wound, observes that the dressing has Montgomery ties in place. The nurse determines this intervention will decrease the risk of which complication?

Skin irritation surrounding the wound

A client is being advanced to a full liquid diet on the second postoperative day. Which foods are allowed for this client? Select all that apply.

Tea Ice cream Cream of tomato soup Cream of wheat cereal

Cloxacillin sodium 100 mg orally every 8 hours is prescribed for a child with an elevated temperature who is suspected of having a respiratory tract infection. The child weighs 17 pounds. The safe pediatric dosage is 50 mg/kg/day. Which statement accurately describes the prescribed dosage for this child?

The dosage is within the safe dosage range.

After attending the same social function 5 days ago, 50 individuals arrive at the hospital over a 4-day period with fever; an itchy, reddish brown papule; and complaints of nausea, vomiting, and severe abdominal pain. Cutaneous anthrax is suspected by the health care team. Which is the nurse's priority for client care?

Institute contact precautions.

A primary health care provider writes a prescription to apply a heating pad to a client's back. The nurse implements the prescription and avoids which action?

Placing the heating pad under the client

A Spanish-speaking client arrives at the triage desk in the emergency department and states to the nurse, "No speak English, need interpreter." Which action should the nurse take?

Seek an interpreter from the hospital's interpreter services.

The nurse is reinforcing instructions about home safety measures regarding medications and toxic substances to a parent. Which parent statements indicate a need for further teaching? Select all that apply.

"I need to refer to medication as 'candy' only when really necessary." "I can place several medications in the same bottle if I am going for an overnight trip."

The nurse educator is describing the yin and yang theory of the ancient Chinese philosophy of Tao to a group of nursing students. The nurse educator explains that in this theory, foods are classified as hot and cold and are transformed into yin and yang energy when metabolized by the body. The nursing student understands this theory when the student makes which statement?

The client consumes cold foods when a "hot" illness is present.

The nurse evaluates that the older client has a need for further teaching on how to promote sleep when the client makes which statements? Select all that apply.

"I drink hot chocolate before bedtime." "I plan out my goals for work for the next day"

The nurse monitors the 3-day postoperative client who underwent abdominal surgery. Vital signs are:temperature: 37.9° C (100.2° F), pulse 104 beats per minute, respirations 22 breaths per minute, blood pressure 128/74 mm Hg. Oxygen saturation is 93% on room air. The client feels tired and has a productive cough. Fine crackles are audible in the bases of the lungs posteriorly. The nurse considers the client has developed which postoperative problem?

Pneumonia

A primary health care provider prescribes tetracycline hydrochloride (0.5 g orally 4 times daily. The medication label on the bottle of medication reads tetracycline hydrochloride 250-mg tablets. The nurse prepares how many tablet(s) to administer 1 dose? Fill in the blank.

2

The nurse is reinforcing instructions to an oriented client and the client's family regarding how to use the patient-controlled analgesia (PCA) pump. The nurse should include which instructions? Select all that apply.

Report an inability to void or bladder discomfort. Explain that the nurse will assess the pain level at frequent intervals. Notify the nurse if the client begins to feel nauseated or is likely to vomit. Instruct the client to push the button when the pain level begins to increase. Explain that there is a lockout on the machine so the client cannot overdose.

The nurse is assisting in caring for a client in transfer from the postanesthesia care unit following nasal surgery. Nasal packing and a mustache dressing are in place. The nurse places the client in which position to best reduce swelling?

Semi-Fowler's

A client with diabetes mellitus calls the clinic nurse to report that the blood glucose level is 150 mg/dL. After obtaining further data from the client, the nurse determines that the client ate lunch approximately 2 hours ago. How should the nurse interpret the data?

The blood glucose level is slightly higher than the normal value.

The primary health care provider (PHCP) has prescribed an antibiotic for a child. The average adult dose is 500 mg. The child has a body surface area (BSA) of 0.63 m2. What is the dose for the child? Fill in the blank.

182.0 mg