Fundamental Skills

A client enters the emergency department confused, twitching, and having seizures. His family states he recently was placed on corticosteroids for arthritis and was feeling better and exercising daily. On data collection, he has flushed skin, dry mucous membranes, an elevated temperature, and poor skin turgor. His serum sodium level is 172 mEq/L. Which interventions would the health care provider likely prescribe? Select all that apply.

-Monitor vital signs. -Monitor electrolyte levels. -Increase water intake orally. -Monitor intake and output. -Maintain sodium-reduced diet.

The nurse is preparing to care for a client with acquired immunodeficiency syndrome (AIDS) who has Pneumocystis jiroveci pneumonia. In planning infection control for this client which should be the appropriate form of isolation to use to prevent the spread of infection to others?

Blood and body fluid precautions

The nurse is preparing to clean up a blood spill on the client's bedside table. The spill occurred when a blood tube containing the client's blood specimen broke. The nurse avoids doing which action when cleaning up the blood spill?

Blotting up the spill with a face cloth or cloth towel

The nurse is preparing to initiate a tube feeding for a client, and the health care provider has prescribed the use of an electronic feeding pump. The nurse brings the pump to the bedside to plug the pump cord into the wall and discovers that there is no available outlet in the wall socket. Which action should the nurse implement?

Contact the electrical maintenance department for assistance.

The nurse is reinforcing discharge instructions to a Chinese client regarding prescribed dietary modifications. During the teaching session the client continually turns away from the nurse. Which nursing action is most appropriate?

Continue with the instructions, verifying client understanding.

The nurse is collecting data from a client who is scheduled for surgery in 1 week in the ambulatory care surgical center. The nurse notes that the client has a history of arthritis and has been taking acetylsalicylic acid (aspirin). The nurse reports the information to the health care provider and anticipates that the provider will prescribe which?

Discontinue the aspirin 48 hours before the scheduled surgery.

A client is scheduled for an oral cholecystography. The nurse should plan to obtain what type of diet for the evening meal before the test?

Fat-free

The nurse is assisting the health care provider in performing a lumbar puncture. The nurse prepares for the procedure by placing the client in which position?

Fetal position

The nurse is preparing to reposition a dependent client who weighs more than 250 pounds. Which intervention is best for the nurse to consider when moving this client?

Find someone who can help.

A client has a diagnosis of hyperphosphatemia. The nurse reinforces teaching the client to eliminate which from the diet?

Fish

The nurse is caring for a client with a health care-associated infection caused by methicillin-resistant Staphylococcus aureus who is on contact precautions. The nurse prepares to provide colostomy care to the client. Which protective items will be required to perform this procedure?

Gloves, a gown, and goggles

The nurse is caring for a client who has been taking diuretics on a long-term basis. Which finding should the nurse expect to note as a result of this long-term use?

Increased specific gravity of the urine

The nurse is assisting in caring for a client immediately following an abdominal surgical procedure who lost a significant amount of blood during surgery. Which finding would indicate a sign of a potential complication?

Increasing restlessness

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. Based on this laboratory value, the nurse should take which action?

Inform the registered nurse of the laboratory value.

The nurse teaches the family of an infant with spina bifida that the infant should not be given which baby foods that may trigger a latex-type food allergy? Select all that apply.

Kiwi Bananas Avocados

A client receiving enteral feedings develops abdominal distention and diarrhea shortly after initiation of the feedings. In review of the nursing history for this client, which of these notations indicates the need to notify the health care provider?

Lactose intolerance since childhood

When positioning for a surgical procedure, the nurse understands that the client's respiratory system is most at risk for dysfunction when in which position?

Lithotomy

The nurse is getting a postoperative client out of bed for the first time since surgery. The nurse raises the head of the bed, and the client complains of dizziness. Which action should the nurse take first?

Lower the head of the bed slowly until the dizziness is relieved.

The nurse is caring for a client with severe diarrhea. The nurse monitors the client closely, understanding that this client is at risk for developing which acid-base disorder?

Metabolic acidosis

The nurse is assisting in caring for a client who is receiving an intravenous infusion of 1000 mL of normal saline with 40 mEq of potassium chloride. The nurse is monitoring the client for signs of hyperkalemia. Which sign/symptom should be noted in the client if hyperkalemia is present?

Muscle weakness

A client presents in the emergency department reporting severe nausea, vomiting, and diarrhea for 5 days. The client is weak, has 2+ tenting skin turgor, and states a weight loss of 7 pounds in the last week. At this time, which action would the nurse take?

Obtain orthostatic vital signs.

The nurse has a prescription to obtain a sample for urinalysis from a client with an indwelling urinary catheter. To prevent contamination of the specimen, the nurse should avoid which action?

Obtaining the specimen from the urinary drainage bag

An adult client has had serum electrolytes drawn. The nurse receiving the results by telephone from the laboratory should be most concerned with which result?

Potassium 5.4 mEq/L

The nurse is assigned to reinforce instructions to a client and the family about the management of home intravenous (IV) infusion therapy. The nurse begins the process by teaching the client and family principles related to what actions first?

Proper hand-washing technique

A client needs to be placed on strict intake and output (I&O) measurement. The nurse collects the data and then checks the client's skin turgor by doing which? Refer to video. Click on the Question Video button to view a video showing preparation procedures.

Pulling up and releasing the skin on the sternal area

The nurse employed in the ambulatory care department hears a client in the waiting room call out, "Help, fire!" The nurse rushes to the waiting room and finds the wastebasket on fire. Which is the immediate action of the nurse?

Remove the clients from the waiting room.

A client has a serum sodium level of 129 mEq/L because of hypervolemia. The nurse consults with the health care provider to determine whether which measure should be instituted?

Restricting fluid intake

A client has returned to the nursing unit following abdominal hysterectomy. To most effectively gather data on the client's postoperative bleeding, the nurse would implement which intervention?

Rolling the client to one side to view bedding

The nurse is reviewing the health records of assigned clients. The nurse should plan care knowing that which client is at risk for a potassium deficit?

The client receiving nasogastric suction

The nurse checks the sternotomy incision of a client on the second postoperative day after cardiac surgery. The incision shows some slight "puffiness" along the edges and is non-reddened with no apparent drainage. The client's temperature is 99° F (37.2° C) orally. The white blood cell (WBC) count is 7500 cells/mm3. Which interpretation does the nurse make of these findings?

The incision line is slightly edematous but shows no active signs of infection.

An ultrasound of the gallbladder is scheduled for the client with a suspected diagnosis of cholecystitis. Which should the nurse explain to the client about this test?

The test requires the client to lie still for short intervals.

A client is admitted to the hospital with a diagnosis of malnutrition. The nurse is told that blood will be drawn to determine whether the client has a protein deficiency. Which laboratory data indicates that the client is experiencing a protein deficiency?

Transferrin, 90 mg/dL

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 and suspects myocardial infarction at the time of chest pain 2 days ago if which comes back positive?

Troponin I

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

A health care provider prescribes laboratory studies on an infant born to a human immunodeficiency virus-(HIV-) positive woman to determine the presence of HIV infection. Which laboratory study should the nurse expect to be prescribed?

p24 antigen assay

Which arterial blood gas (ABG) result should the nurse anticipate in the client with profuse vomiting for 2 days?

pH 7.49; Pco2 45; HCO3- 30

The nurse has completed diet teaching for a client who has been prescribed a low-sodium diet to treat hypertension. The nurse determines that there is a need for further teaching when the client makes which statement?

"Fresh foods such as fruits and vegetables are high in sodium."

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."

A client who has undergone barium enema is being readied for discharge. The nurse determines that the client has understood discharge instructions when the client makes which statement?

"I will be sure the barium passes and watch for my stools to return to normal."

The nurse educator is providing an in-service education to the nursing staff regarding transcultural nursing care. A staff member asks the nurse educator to describe the concept of acculturation. Which response is appropriate?

"It is a process of learning a different culture to adapt to a new or changing environment."

A client with tuberculosis, whose status is being monitored in an ambulatory care clinic, asks the nurse when it is permissible to return to work. What should the nurse tell the client?

"Three sputum cultures must be negative before returning to work."

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 (Motrin) 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? 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 assisting with planning care for a client with an internal radiation implant. Which should be included in the plan of care? Select all that apply.

-Wearing gloves when emptying the client's bedpan -Keeping all linens in the room until the implant is removed -Wearing a film (dosimeter) badge when in the client's room -Wearing a lead apron when providing direct care to the client

A pediatric client with a ventricular septal defect repair is placed on a maintenance dose of digoxin (Lanoxin). The safe dose is 0.03 mg/kg/day, and the client's weight is 7.2 kg. The health care provider (HCP) prescribes the digoxin to be given twice daily. How much digoxin should the nurse administer to the client at each dose?

0.1 mg

Fentanyl 75 mcg intravenous push (IVP) has been prescribed by the health care provider. The medication ampule reads fentanyl 50 mcg/mL. The nurse should prepare how many milliliters to administer the correct dose? Fill in the blank and record your answer using one decimal place.

1.5 mL

A client was diagnosed with acute pancreatitis 10 days ago. The nurse interprets that the episode of acute pancreatitis is fully resolved if the serum lipase level drops to which value?

135 units/L

A client who takes theophylline (Theo-24) for chronic obstructive pulmonary disease (COPD) is seen in the health care clinic. A theophylline level is drawn, and the nurse determines that the client is compliant with the medication regimen if which laboratory result is reported?

15 mcg/mL

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?

21:30

The health care provider prescribes a three-way bladder irrigation of normal saline to be infused at a rate of 200 mL per hour, which infused without problem. There is 1850 mL in the collection receptacle at the conclusion of the 8-hour shift. Which is the client's true urine output for the shift? Fill in the blank.

250 mL

The nurse is preparing to administer a continuous tube feeding to a client with a nasogastric tube. The health care provider has prescribed an amount of 100 mL/hr. How much formula should the nurse plan to add to fill the feeding bag?

400 mL of formula

The nurse determines that an adult male client admitted with dehydration and a hematocrit level of 56% has received adequate fluid volume replacement if which repeat hematocrit level is noted?

48%

A client with hepatic cirrhosis has been consuming a diet with optimal amounts of protein. The nurse determines that the client's consumption of dietary protein has been most effective if the total protein level is which value?

6.8 g/dL

A client is being transferred to the nursing unit from the postanesthesia care unit following spinal fusion with rod insertion. How should the nurse transfer the client from the stretcher to the bed?

A slider board and the assistance of four people

A client is to have an upper gastrointestinal (GI) series. Which nursing action should be done concerning the procedure?

Administer a laxative after the procedure because barium was administered.

The nurse is caring for a client with a diagnosis of amyotrophic lateral sclerosis (ALS). On data collection, the nurse notes that the client is severely dysphagic. The nurse should include which in the plan of care? Select all that apply.

-Allowing the client sufficient time to eat -Providing oral hygiene after each meal -Maintaining a suction machine at the bedside

The nurse determines that which clients are at high risk for metabolic acidosis? Select all that apply.

-Diabetes clients -Kidney failure clients -Malnourishment clients

Which information should the nurse include when reinforcing client teaching regarding ostomy care? Select all that apply.

-Empty pouch when 1/3 to ½ full. -The stoma should be moist and pink to red. -The skin barrier should be within 1/16 to 1/8 inch of the stoma. -Change the appliance about every 3 days, or sooner if it is leaking effluent.

The nurse knows when preparing the Filipino American client for a surgical procedure it is important to assess for which culturally relevant influences? Select all that apply.

-Familial hierarchy -Cultural practices -Reactions to surgery -Pain management plans

A client has been placed on neutropenic precautions. Which information is appropriate when explaining what this means? Select all that apply.

-Get plenty of sleep and rest. -Take all medications as prescribed. -Wash your hands frequently with antibacterial soap.

A client is to be monitored for residual urine every 8 hours. Which are appropriate nursing actions for the nurse to complete this task? Select all that apply.

-Have the client void and then do the bladder scan. -If residual urine is less than 100 mL, continue to monitor.

The nurse is preparing a client for the administration of a tuberculin skin test. The nurse determines that which body areas are appropriate for intradermal injections? Select all that apply.

-Inner aspect of the forearm -Dorsal aspect of the upper arm -Away from heavy pigmentation

The nurse is reinforcing post-procedure teaching after a client underwent an upper gastrointestinal (GI) series. The nurse reminds the client that the stools will remain white for approximately how long?

1 to 2 days

The health care provider prescribes ibuprofen (children's Motrin) 5 mg per kg for a child who weighs 13 pounds. How many milligrams (mg) should the nurse administer to the child? Fill in the blank. Record your answer using one decimal place.

29 mg

A client is transferred from the special care unit to the medical-surgical unit. The nurse receives report and plans to calculate the fall risk. The client is a male, aged 61, admitted to the hospital after being injured in a motor vehicle crash. He has no history of falling. He has no vision or hearing deficits. He has a peripheral continuous intravenous infusion, an indwelling urinary catheter, and sequential compression devices (SCD) while in bed. His gait is steady. He needs supervision when ambulating and uses the call light to contact the nurse for assistance. His prescribed medications include furosemide (Lasix), penicillin (Nafcillin) and ibuprofen (Motrin). He has received ibuprofen (Motrin) twice in the last 24 hours. He is oriented and cooperative. Which score should the client receive based on the fall risk tool? Refer to figure.

9 total points (moderate risk)

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

The skin surrounding a postoperative client's abdominal wound is becoming irritated in the area where the dressing tape is being reapplied with each dressing change. Which is the appropriate nursing action?

Apply Montgomery ties.

The nurse is caring for a child with a diagnosis of roseola. The nurse provides instructions to the mother regarding preventing the transmission of the infection to the other children in the family and the other household members. Which instructions should the nurse reinforce to the mother?

Avoid allowing the children to share drinking glasses or eating utensils because the disease is transmitted through the saliva.

A client receiving total parenteral nutrition complains of nausea, excessive thirst, and increased frequency of voiding. The nurse should initially review which client data?

Capillary blood glucose level

The nurse is reinforcing instructions to a client about the use of an incentive spirometer in the postoperative period. The nurse should include which information in discussions with the client?

The best results are achieved when sitting at least halfway or fully upright.

A health care provider's prescription reads "ketorolac (Toradol), 30 mg intramuscular every 6 hours as needed." The medication label reads "ketorolac (Toradol), 15 mg/mL." The nurse prepares to administer how many milliliters to the client? Fill in the blank.

2 mL

The nurse caring for a Chinese-American client plans to use communication according to Chinese-American cultural beliefs and practices. Which techniques are considered disrespectful in the Chinese-American's view of communication? Select all that apply.

-Maintaining eye contact -Closing the conversation abruptly -Touching the opposite sex in public

The nurse is reviewing the laboratory results of a female adult client suspected of having iron deficiency anemia. The nurse reviews the results and determines that which hemoglobin result is consistent with this diagnosis?

10 g/dL

The nurse is reviewing the health care records of assigned clients. Which client is at risk for excess fluid volume?

The client with renal failure

Penicillin V 250 mg orally every 8 hours, is prescribed for a child with a respiratory infection. The child's weight is 45 pounds. The safe pediatric dosage is 25 to 50 mg/kg/day. Which statement accurately describes the prescribed dosage for this child?

The dosage is within the safe dosage range.

A client is receiving standard oral anticoagulant therapy with warfarin (Coumadin). The result of a newly drawn international normalized ratio is 3.8 seconds. The nurse anticipates carrying out a prescription to do which action?

Hold the next dose of warfarin.

The nurse is comparing the use of nalbuphine (Nubain) versus meperidine (Demerol) for pain management for a pregnant client. Which statement is true with regard to the use of nalbuphine or meperidine?

Nalbuphine is less likely to cause significant respiratory depression.

The nurse is preparing to administer an intermittent tube feeding to a client. The nurse aspirates 90 mL of residual tube feeding. Which action should the nurse take with the aspirated residual?

Reinstill the residual and administer the feeding.

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 performing oral care for a newly admitted client who is undergoing chemotherapy for thyroid cancer. The nurse should take which actions while performing oral care? Select all that apply.

-Provide a soft toothbrush. -Check oral mucous membranes. -Check for missing teeth and cavities.

A client with new onset migraine headaches is being seen in the clinic. The client has a history of hypotension and diabetes mellitus. The nurse predicts that the client will experience undesirable cardiac side effects if the health care provider prescribes which medications? Select all that apply.

-Verapamil (Calan) -Propranolol (Inderal)

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 nurse is assisting in preparing a plan of care for a client who is a Jehovah's Witness. The client has been told that surgery is necessary. Considering the client's religious preferences, the nurse documents which information?

The administration of blood and blood products is forbidden.

A health care provider has written a prescription for calcium carbonate for the client with hypocalcemia. The nurse preparing to administer the medication schedules the medication to be given at which time?

Two hours after meals

A client has just delivered an 8 lb 8 oz infant boy after a prolonged labor. The pediatrician prescribes ampicillin 50 mg to be given by the intramuscular route to the newborn every 8 hours. The nurse is initiating the first dose. Ampicillin is available in powder form for injection. The directions on the bottle indicate reconstitution with 0.9 mL of sterile diluent for a concentration of 125 mg/mL. How many milliliters (mL) should the nurse prepare to administer the first dose? Fill in the blank.

0.4 mL

A health care provider prescribes an intramuscular (IM) dose of 250,000 units of penicillin G benzathine (Bicillin). The label on the 10-mL ampule sent from the pharmacy reads penicillin G benzathine 300,000 units/mL. How much medication will the nurse prepare to administer the correct dose? Fill in the blank. Record your answer to one decimal place.

0.8 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

Calcitriol (Rocaltrol) is prescribed for the client with hypocalcemia. The nurse instructs the client to avoid excessive amounts of which food item that interfere with calcium absorption?

Bran

A client with a burn injury is transferred to the nursing unit and a regular diet has been prescribed. The nurse encourages the client to eat which dietary items to promote wound healing?

Chicken breast, broccoli, strawberries, and milk

The nurse is preparing a client for surgery. Which would be a component of the plan of care?

Review the results of the preoperative laboratory studies.

A client is being discharged to home following spinal fusion with insertion of rods. For which home environment situation should the nurse suggest a consultation with the continuing care nurse?

The bedroom and bath are on the second floor of the home.

A client who is receiving total parenteral nutrition may begin to take small amounts of clear liquids today. The nurse's priority is to collect data regarding which criterion before giving the client anything by mouth?

The presence of the swallow reflex

The nurse assists to conduct a home safety assessment with a client preparing for discharge, and the client tells the nurse that a space heater is used to heat the apartment. Which instruction should the nurse provide to the client regarding the use of the space heater?

The space heater needs to be placed at least 3 feet from anything that can burn.

The nurse is administering intramuscular iron to an assigned client. The nurse should take which action to avoid skin staining around the injection site?

Use a Z-track method for administration.

The nurse is assigned to care for a client who has been diagnosed with human immunodeficiency virus (HIV). In planning care for the client, the nurse understands that educating staff concerning which instruction will have the greatest impact on minimizing the spread of the virus?

Using personal protective equipment appropriately

The nurse is administering mouth care to an unconscious client. The nurse should avoid doing which?

Using products with lemon or alcohol

A health care provider's prescription reads potassium chloride 20 mEq in 1000 mL normal saline and infuse at 100 mL/hr. The nurse assisting in caring for the client determines that the client will receive how many milliequivalents (mEq) of potassium every hour? Fill in the blank.

2 mEq

A client diagnosed with bipolar disorder is prescribed oral lorazepam (Ativan) 4 mg daily to help manage his manic behavior. The medication label reads 2 mg/mL. To ensure the correct dose, the nurse administers how many milliliters per dose? Fill in the blank.

2 mL

A health care provider prescribes tetracycline hydrochloride (Sumycin) 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 one dose? Fill in the blank.

2 tablets

The nurse working in a human immunodeficiency virus (HIV)/acquired immunodeficiency (AIDs) clinic is reviewing modes of transmission for HIV for a new nurse to the clinic. Which potential modes of HIV transmission should the nurse review? Select all that apply.

-Needle-stick injuries -Transmission by breast milk -Transfusion of HIV infected blood -Inconsistent use of protective equipment

A client has been diagnosed with functional incontinence. Which interventions are 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.