Fundamental dynamic quizzes easy

A nurse is using the I-SBAR communication tool to give a client's provider information about the client. The nurse should convey this client's pain status in which portion of the report? A. Assessment B. Background C. Situation D. Recommendation

A. Assessment rationale: The nurse provides information about assessment findings in this portion of the report, including vital signs, pain assessment, and changes in assessment findings. B. The nurse provides information about pertinent medical history, laboratory findings, allergies, and code status in this portion of the report. C. The nurse provides information about problems the client is experiencing in this portion of the report. D. The nurse makes recommendations about treatment and asks the provider about additional treatment in this portion of the report.

A nurse is caring for a client who is receiving a blood transfusion. The client reports flank pain, and the nurse notes reddish-brown urine in the client's urinary catheter bag. The nurse recognizes these manifestations as which of the following types of transfusion reactions? A. Hemolytic B. Febrile C. Circulatory overload D. Sepsis

A. Hemolytic rationale: A hemolytic reaction occurs when the client's blood is incompatible with the donor's blood. Chills, low back pain, hypotension, and tachycardia are indications of a hemolytic transfusion reaction. B. A febrile reaction occurs when the client's blood is sensitive to the WBCs and platelets in the donor's blood. Fevers, chills, headaches, and flushing are indications of a febrile reaction. C. Circulatory overload occurs when blood is administered too quickly for the client's circulatory system to handle. Dyspnea, coughing, headaches, and hypertension are indications of circulatory overload. D. Sepsis occurs when the blood is contaminated with bacteria. High fevers, vomiting, and diarrhea are indications of sepsis.

A nurse is caring for a client who is exhibiting confusion. The nurse should identify which of the following laboratory values can cause confusion? A. Sodium 123 mEq/L B. Blood glucose 100 mg/dL C. Potassium 3.5 mEq/L D. Hemoglobin 13 g/dL

A. Sodium 123 mEq/L rationale: A sodium level of 123 mEq/L is below the expected reference range of 136 to 145 mEq/L. Low sodium levels can cause confusion and lead to seizures, coma, and death. B. A blood glucose of 100 mg/dL is within the expected reference range of 70 to 110 mg/dL for fasting and less than 200 mg/dL for a casual blood draw. C. A potassium level of 3.5 mEq/L is within the expected reference range of 3.5 to 5 mEq/L. D. A hemoglobin level of 13 g/dL is within the expected reference range of 12 to 18 g/dL.

A nurse is caring for a client who is postoperative and has paralytic ileus. Which of the following abdominal assessments should the nurse expect? A. Frequent bowel sounds with flatus B. Absent bowel sounds with distention C. Hyperactive bowel sounds with diarrhea D. Normal bowel sounds with increased peristalsis

B. Absent bowel sounds with distention rationale: With paralytic ileus, bowel sounds are absent, the abdomen is distended, and there is no flatus or stool.

A nurse is called away for an emergency while conversing with a client who is concerned about his medical diagnosis. The nurse returns to the client promptly, as promised. Which of the following ethical principles is the nurse demonstrating? A. Autonomy B. Fidelity C. Nonmaleficence D. Justice

B. Fidelity Fidelity - keeping a promise that was made Autonomy - right to make personal decisions Nonmaleficence - do no harm Justice - treat fairly

A nurse is supervising a newly licensed nurse who is caring for a client with streptococcal pharyngitis and is on transmission-based precautions. Which of the following actions by the newly licensed nurse indicates an understanding of droplet precautions? A. Shaking soiled linen before putting it in a hamper B. Removing a face mask when standing 0.5 m (1.6 ft) from the client C. Assigning another client with the same infection to share the room with the client D. Allowing the client to visit a family member in the lobby of the facility

C. Assigning another client with the same infection to share the room with the client

A nurse is caring for a client who had a stroke and is at risk of falling. Which of the following actions should the nurse take? A. Assign the client to a private room B. Keep 4 side rails up while the client is in bed C. Monitor the client at least once every hour D. Request a PRN prescription for restraints

C. Monitor the client at least once every hour B. The use of 4 raised side rails on the client's bed is considered a physical restraint that the nurse cannot employ without a prescription from the provider. Bed rails can increase a client's fall risk if the client attempts to climb over the rails to get out of bed.

A nurse is reviewing the correct use of a fire extinguisher with a client. Which of the following actions should the nurse direct the client to take first? A. Aim the hose at the base of the fire. B. Squeeze the handle of the extinguisher. C. Remove the safety pin from the extinguisher. D. Sweep the hose from side to side to dispense material.

C. Remove the safety pin from the extinguisher.

A nurse in the emergency department is caring for a client who has abdominal trauma. Which of the following assessment findings should the nurse identify as an indication of hypovolemic shock? A. Warm, dry skin B. Increased urinary output C. Tachycardia D. Bradypnea

C. Tachycardia A. Cool, clammy skin is an indication of hypovolemic shock. B. Urine output of ≤30 mL/hr is an indication of hypovolemic shock. D. Tachypnea is an indication of hypovolemic shock.

A nurse is planning care for an adult client who has fluid volume excess. What intervention should the nurse plan to include to monitor the patient's weight? A. Calibrate the scales weekly B. Use a different scale each time C. Weigh the client on arising D. Weigh the client without clothing

C. Weigh the client on arising

A nurse observes an assistive personnel (AP) preparing to obtain blood pressure with a regular-sized cuff for a client who is obese. Which of the following explanations should the nurse give the AP? A. "The reading will be inaudible if the cuff is too small for the client." B. "The width of the cuff bladder should be 75% of the circumference of the client's arm." C. "As long as the cuff will circle the arm, the reading will be accurate." D. "Using a cuff that is too small will result in an inaccurately high reading."

D. "Using a cuff that is too small will result in an inaccurately high reading."

A nurse documents the presence of clubbing of the fingernails for a client who has emphysema. Which of the following is the underlying cause of this finding? A. Trauma B. Severe infection C. Iron-deficiency anemia D. Chronic hypoxemia

D. Chronic hypoxemia rationale: Clubbing of the nails of the fingers and toes is the result of chronic hypoxemia (low oxygen supply) such as with COPD. It is a change in the angle between the nail and the nail base, often with enlargement of the fingertips.

A nurse is caring for a client who has the head of his bed elevated to a 45° angle with his knees slightly flexed. Which of the following positions should the nurse document for the client? A. Sims' B. Prone C. Supine D. Fowler's

D. Fowler's

A nurse is caring for a client who is postoperative following vascular surgery on the left femoral artery. The nurse should identify that the surgical wound should be cleansed in which of the following directions? A. From the middle of the thigh toward the wound B. From the left lower abdominal quadrant toward the wound C. From the left hip toward the wound ✔ D. From the wound toward the surrounding skin

D. From the wound toward the surrounding skin rationale: The nurse should cleanse a surgical wound from the least contaminated location (the inside of the wound) toward the most contaminated (the surrounding skin).

A nurse is changing the dressings for a client who is 3 days postoperative following a cholecystectomy. The nurse observes yellow, thick drainage on the dressing. The nurse should document this finding as which of the following types of drainage? A. Sanguineous exudate B. Serous exudate C. Serosanguineous exudate D. Purulent exudate

D. Purulent exudate rationale: Purulent exudate on the client's dressings includes thick yellow, green, or brown drainage and usually indicates wound sloughing or infection. A. Sanguineous exudate drainage on the client's dressings indicates an accumulation of RBCs from the plasma that appears bright red on the dressings. B. Serous exudate drainage on the client's dressings indicates plasma from the blood and appears watery and clear to light yellow in color. C. Serosanguineous exudate drainage on the client's dressings indicates plasma mixed with light bloody drainage, which is typically pale yellow to blood-tinged. Watery drainage may also be evident.

How often should a ostomy pouch be changed? When should the bag be changed?

every 3-7 days - before meals