Fundamentals 2

a nurse is teaching a new group of assistive personnel (AP) about the importance of hang hygiene. which of the following statements should the nurse include? a. "if you wear gloves, you do not have to wash your hands." b. "rub all surfaces of your hands with an alcohol rub for 20 to 30 seconds." c. "use an alcohol rub when your hands are visibly soiled." d. "if you don't have an infection, your hands won't infect others."

b.

a nurse is preparing to infuse a 250-mL unit of packed RBCs over 2 hr. the drop factor of the manual IV tubing is 15gtts/mL. the nurse should adjust the flow rate to deliver how many drops per minute?

31 gtt/min

a nurse is orienting a newly licensed nurse about documenting of a client's information in the electronic health record. which of the following statements by the newly licensed nurse indicates understanding of the purpose of documentation? a. "documentation is a communication tool for the interprofessional health care team." b. "documentation provides information to the client about financial charges for care provided." c. "documentation provides information for a client adult." d. "documentation allows providers to monitor the nurse's activities."

a.

a nurse is performing tracheostomy care for a client and suctioning to remove copious secretions. which of the following actions should the nurse take? a. suction two to three times with a 60-second pause between passes b. perform chest physiotherapy prior to suctioning c. lubricate the suction catheter tip with sterile saline d. hyperventilate the client on 100% oxygen prior to suctioning

a.

a nurse is caring for a group of clients on a medical-surgical unit. which of the following situations requires that the nurse wear gloves? (select all that apply) a. emptying urine from an indwelling urine collection bag b. providing oral care c. changing an stony pouch d. delivering a food tray to a client who has AIDS e. placing oral medication tablets into a client's hand

a. b. c.

The nurse is removing personal protective equipment (PPE). Which item should be removed first? a. gown b. gloves c. face shield d. mask

b.

a nurse intercepts a messenger at the nurses' station who has a flower delivery for a client on the unit. as the nurse accepts the flowers, the messenger says, "I know Mrs. Welch from the neighborhood. what happened to her?" which of the following responses should the nurse provide? a. "you know it's not appropriate for you to ask me that." b. "it's my responsibility to remind you that we have to respect our clients' privacy." c. "it's a minor injury. I'm sure you'll see her back in the neighborhood soon." d. "oh, what lovely flowers. she will enjoy these."

b.

a nurse is caring for a client who has active pulmonary tuberculosis (TB). the client requires airborne precautions and is receiving multidrug therapy. which of the following precautions should the nurse take to transport the client safely to the radiology department for a chest x-ray? a. ask the x-ray technician to come to the client's room to obtain a portable x-ray b. have the client wear a mask c. notify the x-ray department that the client requires airborne precautions d. wear the filtration mask and gloves during transport

b.

a nurse caring for a client is using active listening skills. which of the following action should the nurse take? a. sit side-by-side with the client b. have a pen and paper handy c. use intermittent eye contact d. lean back in the chair

c.

a nurse in a clinic is interviewing a client who will undergo diagnostic testing. the nurse should ask about a client's potential allergies during which phase of the nursing process? a. planning b. evaluation c. assessment d. implementation

c.

a nurse is completing a client's history and physical examination. which of the following information should the nurse consider subjective data? a. blood pressure b. cyanosis c. nausea d. petechiae

c.

a nurse is developing a plan of care for a client who practices Islam. which of the following actions should the nurse include in the plan? a. serve foods that have hot-cold balance b. serve milk products separately from meals c. request a meal tray without pork d. remove tea and coffee from meal trays

c.

a nurse is planning home care for a 9-year-old child following an acute exacerbation of asthma. which of the following of Erikson's developmental stages should the nurse consider in the planning? a. autonomy vs. shame and doubt b. initiative vs. guilt c. industry vs. inferiority d. identity vs. role confusion

c.

a nurse in a long-term facility is observing an assistant personnel (AP) changing the linen for a client who has fecal incontinence. which of the following actions indicates that the AP understands the principles of infection control? a. shakes the solid linen to remove any toilet paper remnants b. places the solid linen on the floor before bagging it c. holds the soiled linen against her body while carrying it to the linen bag d. places clean linen that touched the floor in the soiled linen bag

d.

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? a. creatine kinase b. troponin c. total bilirubin d. albumin

d.

a nurse is performing a cardiac assessment. identify where the nurse should place the stethoscope to auscultate the client's apical pulse. a. 2nd intercostal space right side b. 2nd intercostal space left side c. 4th intercostal space left side d. fifth intercostal space left side

d.

a nurse is providing preoperative teaching by demonstrating diaphragmatic breathing to a client who is scheduled for surgery in the morning. which of the following actions should the nurse include in the demonstration? a. place her hands on the sides of her rib cage b. inhale slowly and evenly through her nose c. hold her breath for at least 10 seconds d. exhale forcefully through the nose

b.

a nurse is receiving change-of-shift report for a group of assigned clients. the nurse anticipates which of the following activities first in delivering client care using the nursing process? a. critically analyze client data to determine priorities b. collect and organize client data c. set client-centered, measurable and realistic goals d. determine effectiveness of interventions

b.

a nurse is attending a social event when another guest coughs weakly once, grasps his throat with his hands, and cannot talk. which of the following actions should the nurse take? a. observe the client before taking further action b. perform the Heimlich maneuver c. assist the client to the floor and begin mouth-to-mouth resuscitation d. slap the client on the back several times

b.

a nurse is caring for a client who has had an allogeneic hematopoietic stem-cell transplant. which of the following infection-control precautions should the nurse use while caring for this client? a. airborne b. protective c. contact d. droplet

b.

a nurse is planning care for a client who has a decreased level of consciousness. the client is receiving continuous enteral feeding via a gastrostomy tube due to an inability to swallow. which of the following is the priority action by the nurse? a. observe client's respiratory status b. elevate the head of the client's bed to 30* to 45* c. monitor intake and output every 8 hr d. check residual volume every 4 to 6 hr

b.

a nurse is planning care for a client who requires airborne precautions. which of the following actions should the nurse take? a. provide a positive-pressure airflow room b. wear an N95 respirator mask c. allow the client to ambulate in the hall d. stand 1.8m (6 feet) from the client

b.

a nurse is preparing an educational program for a group of newly licensed nurses about client confidentiality. the nurse should explain that nurses may share a client's protected health information with which of the following groups? a. the client's immediate family members b. clergy affiliated with the facility c. the facility's administrators d. health care team members caring for the client

d.

a nurse is preparing to obtain a blood specimen from a client by venipuncture. the client is receiving IV fluids through an IV catheter inserted in the basilica vein of the right forearm. which of the following sites should the nurse plan to use to obtain the blood specimen? a. left upper arm b. right forearm c. foot d. left forearm

d.

a nurse is reviewing a client's prescription for 1,000 mL of 5% dextrose in water IV to infuse over 8 hr. at 1400, the nurse observes that there is 500 mL of solution remaining in the client's current IV bag. at what time should the nurse administer the next bag of IV solution? a. 1500 b. 1600 c. 1700 d. 1800

d.