FINAL FUNDEMENTAL

A nurse in a PACU is assessing a client who has a newly created colostomy. Which of the following findings should the nurse report to the provider? ⁃

Purplish colored stoma

A nurse is caring for a client who has cancer and is receiving total parenteral nutrition (TPN). Which of the following lab values indicates the treatment is effective?

⁃ Albumin 4.2 g/dL

A nurse is providing skin care for a client who has urinary incontinence. Which of the following actions should the nurse take?

⁃ Apply a barrier cream to the clients skin

A nurse is caring for a client who had radiation therapy and is experiencing painful dermatitis. The nurse should identify the client is experiencing which of the following types of pain?

⁃ Cancer pain

A nurse is caring for a client who is 2 days postoperative following abdominal surgery and observes that the client's wound has eviscerated. After calling for help, Which of the following actions should the nurse take first?

⁃ Cover the area with a sterile dressing, moistened with 0.9% sodium chloride irrigation

A nurse is caring for a client who requests prescription pain medication. Which of the following actions should the nurse perform first?

⁃ Determine the location of the pain

A nurse prepares to replace the nearly empty container of total parenteral nutrition (TPN) for a client when she finds that there has been a delay in receiving the new container of solution from the pharmacy. Which of the following solutions should the nurse infuse until the next container of TPN solution becomes available?

⁃ Dextrose 10% in water

A nurse is caring for a client who is scheduled for surgery. The nurse is reviewing the client's medical record. Which of the following findings places the client at risk for delayed wound healing? (SATA)

⁃ Diabetes mellitus ⁃ Medication history ⁃ Pre albumin level

A nurse is preparing to insert an indwelling urinary catheter for a client. Which of the following actions should the nurse plan take?

⁃ Don sterile gloves before inserting the indwelling urinary catheter

A nurse is planning care for a client who requires screening for rectal cancer. Which of the following tests should the nurse anticipate in the client's plan of care?

⁃ colonoscopy

A nurse is assessing a client who has obstructive sleep apnea (OSA). Which of the following findings should the nurse expect?

⁃ decreased energy

A nurse is caring for a client who is receiving enteral tube feeding and has a new prescription to dilute the formula. The nurse recognizes this is being done to resolve which of the following conditions?

⁃ diarrhea

A nurse is instructing a client's family members about feeding safety for a client who has dysphagia following a stroke. Which of the following instructions should the nurse include?

⁃ encourage the client to take small bites

A nurse is planning care for a client who has a superficial wound with no exudate. The nurse should plan to use which of the following dressings to cover the wound?

⁃ film dressing

A nurse is preparing to irrigate a wound for a client. Which of the following actions should the nurse plan to take?

⁃ irrigate the wound until the solution that is draining is clear

A nurse is assessing a client for manifestations of pain. Which of the following findings is a subjective indicator of pain?

⁃ the client reports a burning sensation

A nurse is caring for a client who receives intermittent enteral feedings through an NG tube. Before administering a feeding, the nurse should measure the gastric residual for which of the following purposes?

⁃ to identify delayed gastric emptying

A nurse is preparing to insert an NG tube for a client who requires gastric suctioning. Place the following steps in the appropriate order. (Move the steps of NG tube placement into the box on the right, placing them in the selected order of performance. Use all the steps.)

1. Prepare equipment at the bedside. 2. Measure the NG tube. 3. Instruct the client to extend the neck backward. 4. Instruct the client to flex the head forward. 5. Obtain an x-ray. 6. Connect the tube to the suction device.

A nurse is assessing a client who has impaired mobility. The nurse should monitor the client for a pressure injury due to which of the following factors? ⁃

decreased circulation

A nurse is caring for a client who is receiving total parenteral nutrition (TPN). The pharmacy is delayed in supplying the client's next container of TPN. Which of the following fluids should the nurse infuse until the next container arrives?

dextrose 10% in water

A nurse is providing discharge teaching to a client who will be receiving total parenteral nutrition (TPN) at home. Which of the following instructions should the nurse include? (SATA)

⁃ "Keep the TPN refrigerated when not in use." ⁃ "Infuse 10 percent dextrose and water if the solution runs out." ⁃ "Maintain TPN infusion rate when behind schedule."

A nurse is caring for a client who has an NG tube. The nurse tests the pH of the secretions to determine if the tube is correctly placed. Which of the following readings should the nurse expect?

⁃ 4.0

A nurse is assessing a client who has a wound that is healing by first intention. Which of the following findings should the nurse expect?

⁃ Skin edges of the wound are sutured closed

A nurse is caring for a client who is postoperative. The nurse should base her pain management interventions primarily on which of the following methods of determining the intensity of the client's pain?

⁃ The clients self report of pain severity

A charge nurse observes a nurse administer intermittent tube feedings via an NG tube to a client. Which of the following actions should prompt the charge nurse to intervene?

⁃ The nurse allows the client to rest in a supine position during feeding

A nurse is preparing to remove an NG tube from a client. Which of the following actions should the nurse take first?

⁃ Verify the providers prescription to discontinue the tube

A nurse is assessing a client who has an infection. Which of the following findings is a manifestation of sepsis? (SATA)

⁃ Vomiting ⁃ Altered mental status ⁃ Elevated WBC count

A nurse is teaching a client who is preoperative for an ileostomy. Which of the following statements should the nurse include?

⁃ You will have a stoma placed in your right lower abdomen

A nurse is teaching a class about sleep disorders. The nurse should include that which of the following conditions can cause obstructive sleep apnea (OSA)?

⁃ enlarged tonsils

A nurse is assessing a client and discovers the infusion pump with the client's total parenteral nutrition (TPN) solution is not infusing. The nurse should monitor the client for which of the following conditions?

⁃ shakiness and diaphoresis

A nurse is caring for a client who requires total parenteral nutrition (TPN). Which of the following actions should the nurse take when finding that the TPN solution is infusing too rapidly?

⁃ sit the client upright

A nurse is teaching a newly licensed nurse about pain. Which of the following is an example of acute pain?

⁃ surgical incision

A nurse is caring for a client in a long-term care facility who is receiving enteral feedings via an NG tube. Which of the following actions should the nurse take prior to administering the tube feeding?

⁃ test the PH of gastric aspirate

A nurse is assessing a client for manifestations of pain. Which of the following findings is an objective indicator of pain?

⁃ the client grimaces when they move

A nurse is planning care for an older adult client who is at risk for developing pressure ulcers. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin?

⁃ use a transfer device to lift the client up in bed

A nurse is caring for a client who has methicillin-resistant Staphylococcus aureus (MRSA) in an abdominal wound. The nurse enters the room to check the client's pulse. Which of the following actions should the nurse take?

⁃ wear clean gloves

A nurse is providing teaching to a client who has a new colostomy. Which of the following information should the nurse include in the teaching?

⁃ you may experience a small amount of bleeding around the stoma

A nurse is providing discharge teaching for a patient with a fractured humerus. The patient is going home with a prescription for hydrocodone. Which important patient education should the nurse provide?

⁃ you need to drink plenty of fluids and eat a diet high in fiber

A nurse is teaching a client about using a PCA device for postoperative pain management. Which of the following statements should the nurse make?

⁃ you will have control of administering your own pain medication

A nurse is teaching a client who has urinary incontinence about avoiding foods and beverages that can cause bladder irritation. The nurse should include that which of the following foods and beverages is a bladder irritant?

Caffeinated beverages

A nurse is caring for a light-skinned client who has an ileostomy. The nurse is reviewing the client's medical record. Click to highlight the findings that require intervention by the nurse. To deselect a finding, click on the finding again. (SATA)

Day 1 ⁃ Client will not look at stoma ⁃ Client states they are not interested in learning about stoma care. Day 2 ⁃ Skin surrounding stoma is reddened and has small open areas. ⁃ Stoma with small amount of bleeding noted during cleaning.

A nurse is assessing a client who has a colostomy. Which of the following findings should the nurse report to the provider?

The stoma is pale in color

A nurse is assessing a client who has had diarrhea for several days. Which of the following findings should the nurse expect?

dehydration

A nurse is preparing to initiate a continuous enteral feeding through an open system to a client. Which of the following actions should the nurse take?

discard unused formula after 8 hours

A nurse caring for a client who has an infected wound removes a dressing saturated with blood and purulent drainage. How should the nurse dispose of the dressing material?

dispose of the dressing in a bio hazardous waste container

A nurse is assessing a client who is nonverbal for acute pain. Which of the following findings is a manifestation of pain?

elevated blood pressure

A nurse is preparing to witness informed consent for a client who is preoperative. The client asks the nurse, "Are there other options besides surgery?" Which of the following responses should the nurse make?

have you discussed other treatments with your provider

A nurse is caring for a client who has phantom limb pain. The nurse should identify the client is experiencing which type of pain?

neuropathic pain

A nurse is caring for a client. Drag 1 condition and 1 client finding to fill in each blank in the following sentence.

the client is at greatest risk for developing pressure injury due to urinary incontinence and immobility

A nurse is teaching a client who is preoperative for a sigmoid colostomy. Which of the following statements should the nurse include?

you will have a stoma in your lower left abdomen

A nurse is teaching a newly licensed nurse about pain management during the end of life. Which of the following statements should the nurse make?

⁃ "Clients are often afraid that opioid narcotics can result in addiction."

A nurse is caring for a client who is 9 days postoperative following a total laryngectomy. The nurse removes the client's NG tube and initiates oral feedings. Which of the following statements should the nurse make?

⁃ "It is no longer possible for you to choke on or aspirate food."

A nurse is caring for a client who is receiving total parenteral nutrition (TPN). The nurse notices that the solution bag is almost empty and there is not another bag of TPN to administer. Which of the following IV solutions should the nurse administer until the next bag of TPN solution is available?

⁃ 10% dextrose in water (D10W)

A nurse is caring for a group of clients. Which of the following clients should the nurse identify is at highest risk for developing a pressure injury?

⁃ A client who is unresponsive to verbal commands and changes position occasionaly

A nurse is teaching a newly licensed nurse about ethical principles. Which of the following is an example of justice?

⁃ A nurse provides nonpharmacological pain interventions to each client equally.

A nurse is teaching a class about the use of pain medications for clients who have an opioid addiction. Which of the following medications are a nonopioid analgesic? (SATA)

⁃ Acetaminophen ⁃ Ibuprofen

A nurse is administering several medications via a client's gastrostomy tube. At which of the following times should the nurse instill 15 to 30 mL of warm water? (SATA)

⁃ After each meditation ⁃ Prior to administering each medication ⁃ After giving multiple medications

A nurse is assessing a client who has urinary retention. Which of the following findings should the nurse expect?

⁃ leakage of urine

A nurse is teaching a class about sleep. The nurse should include that which of the following hormones regulates the sleep-wake cycle?

⁃ melatonin

A nurse is prioritizing care for two clients at the start of the shift. The first client, who is 1 day postoperative following a partial bowel resection, requires a dressing change, total parental nutrition administration and reports a pain level of 6 on a scale from 0 to 10. The second client, who has a newly inserted percutaneous gastrostomy tube, requires a tube feeding, dressing change, and daily weight. Which of the following nursing actions should the nurse plan to complete first?

⁃ obtain vital signs for both clients

A nurse is assessing a client who has a stage 2 pressure injury. Which of the following findings should the nurse expect?

⁃ partial thickness skin loss with red tissue in wound bed

A nurse is assessing a client who received an opioid narcotic for incisional pain. Which of the following findings is the priority?

⁃ pulse oximetry

A nurse is caring for a client who reports abdominal pain. The nurse asks the client to describe what the pain feels like. The nurse is using which of the following components of the PQRST mnemonic?

⁃ quality

A nurse is teaching a client who reports insomnia. Which of the following statements should the nurse make?

⁃ remove the television from your bedroom

A nurse is caring for a client who reports insomnia. Which of the following actions should the nurse take?

⁃ restrict visitors when the client is sleeping

A nurse is performing a pain assessment for a client who is alert. The nurse should recognize that which of the following measures is the most reliable indicator of pain?

⁃ self report of pain

A nurse is assessing a client's wound dressing, and observes a watery red drainage. The nurse should document this drainage as which of the following?

⁃ sero sanguineous

A nurse is caring for a client who reports back pain. The nurse asks the client to rate the pain on a scale of 0 to 10. The nurse is using which of the following components of the PQRST mnemonic?

⁃ severity

A nurse is preparing to administer an enteral feeding via nasogastric tube. Identify the correct sequence the nurse should follow to initiate the feeding. (Move the steps into the box on the right, placing them in the selected order of performance. All steps must be used.)

1. Verify tube placement 2. Check the residual feeding contents 3. Administer the feeding 4. Evaluate tolerance of feeding

A nurse is caring for a client who has a wound infection. Which of the following actions should the nurse take when obtaining a wound-drainage specimen for culture?

Cleanse the wound with 0.9% sodium chloride saline irrigation before obtaining the specimen

A nurse is preparing to administer three liquid medications to a client who has an NG feeding tube with continuous enteral feedings. Which of the following actions should the nurse take?

⁃ Flush the NG feeding tube with 30 mL of water immediately following medication administration

A nurse on the day shift is preparing to change a client's total parenteral nutrition (TPN) solution, but the new TPN solution has not arrived from the pharmacy. The client receives additional IV fat emulsion during the night shift. Which of the following actions should the nurse take?

⁃ Hang dextrose 10% in water (D10W) until the TPN solution is delivered

A nurse is assessing a client who is receiving total parenteral nutrition (TPN). Which of the following findings should the nurse recognize as a complication of this therapy?

⁃ Hyperglycemia

A nurse is teaching a client's adult son about how to position the client when administering enteral feedings at home. Which of the following statements by the son indicates an understanding of the teaching?

⁃ I will have him sit in his chair during the feeding

A nurse is discharge teaching with a client about medications. Which of the following client statements indicate an understanding?

⁃ I will store narcotic medications in the original package

A nurse is assessing a client who has a stage 1 pressure injury. Which of the following findings should the nurse expect?

⁃ Intact skin with localized erythema

A nurse is caring for a client who is postoperative. Click to highlight the documentation in the client's medical record that require further action by the nurse? To deselect a finding, click on the finding again. (SATA) ⁃ Client is difficult to arouse. ⁃ Respirations 10/min

⁃ Pulse oximetry 89% on room air

A nurse is caring for a client. Click to highlight the findings that require follow-up. To deselect a finding, click on the finding again. (SATA) )

⁃ Redness noted at wound borders, skin surrounding wound is warm to touch ⁃ purulent drainage noted ⁃ - Temp 38.9° C (102° F) ⁃ - WBC 13,500/mm? (5000 to 10,000 mm%

A nurse is preparing to obtain a 24-hr urine collection from a client. Which of the following actions should the nurse plan to take?

⁃ Refrigerate the urine during the collection time period.

A nurse is planning care for a client who is to start receiving total parenteral nutrition (TPN). Which of the following interventions should the nurse include in the plan of care?

⁃ Use a 1.2 micron filter when infusing TPN with fat emulsions added.

A nurse is teaching a newly licensed nurse about ethical principles. Which of the following is an example of beneficence?

⁃ a nurse administers pain medication for a client who is having pain

A provider prescribes a sublingual medication for a client who has an NG tube in place. Which of the following actions should the nurse take?

⁃ administer the medication under the clients tongue

A nurse is admitting a client who reports anorexia and is experiencing malnutrition. Which of the following laboratory findings should the nurse expect to be altered?

⁃ albumin

A nurse in an emergency department is caring for a client who has a deep laceration on her left lower forearm and is bleeding heavily from the wound. Which of the following interventions should the nurse perform first?

⁃ apply pressure directly to the wound

A nurse is planning care for a client who is receiving enteral feedings through an NG tube. Which of the following actions should the nurse plan to take first?

⁃ aspirate the clients stomach contents

A nurse is assessing a client who is receiving total parenteral nutrition (TPN) therapy via an infusion pump. Which of the following actions should the nurse take?

⁃ change the IV tubing every 24 hours

A nurse is caring for a client who came to the emergency department with abdominal distention and is now on the medical-surgical unit with an NG tube in place to low gastric suction. The client is reporting anxiety, discomfort, and a feeling of bloating. Which of the following actions is the nurse's priority?

⁃ check to see if the suction equipment is working

A nurse is administering an enteral feeding through a client's NG tube. Which of the following actions should the nurse take?

⁃ cleanse the top of the can of formula with an alcohol wipe

A nurse is planning care for a client who has a decreased level of consciousness. The client is receiving continuous enteral feedings via a gastrostomy tube due to an inability to swallow. Which of the following is the priority action by the nurse?

⁃ elevate the head of the clients bed 30* to 45* degrees

A nurse is caring for four clients who have drainage tubes. Which of the following clients should the nurse recognize as being at risk for hypokalemia?

⁃ the client who has a nasogastric NG Tube to suction