Fundamentals 2 Quiz

A nurse is caring for a client who is postoperative following a vaginal hysterectomy and asks for a drink. Her postoperative diet prescription reads: clear liquids; advance diet as tolerated. Which of the following responses should the nurse make?

"I am going to listen to your abdomen."; to determine the presence of bowel sounds before clear liquids can be administered.

A nurse is assessing a client who has an onset of severe back pain of unknown origin. Which of the following questions should the nurse ask to encourage discussion with the client?

"What do you think caused the onset of your pain?"

A nurse is planning care for a group of clients who are receiving oxygen therapy. Which of the following clients should the nurse plan to see first?

A client who has heart failure and is receiving 100% oxygen via a partial rebreather mask; the nurse should frequently check the bag on a rebreather mask to ensure it inflates properly. If the bag is deflated, the client will rebreathe his own exhaled carbon dioxide instead of receiving the prescribed oxygen dose.

A nurse is changing the dressings for a client recovering from an appendectomy following a ruptured appendix. The client's surgical wound is healing by secondary intention. Which of the following observations should the nurse report to the provider?

A halo of erythema on the surrounding skin

A nurse is caring for a client who has major fecal incontinence and reports irritation in the perianal area. Which of the following actions should the nurse take first?

Check the client's perineum

A nurse is assisting a client who is eating at mealtime. The client grabs her neck with both hands and appears frightened. Which of the following actions should the nurse take first?

Determine whether the client is able to breathe

A nurse is replacing the surgical dressings on a client who had abdominal surgery. Which of the following action should the nurse take?

Don clean gloves to remove the old dressing; Sterile gloves are not necessary until the nurse applies the new sterile dressing.

A nurse is preparing to administer eye drops to a client following surgery. Which of the following actions should the nurse take when instilling the eye drops?

Drop the eye medication in the outer third of the lower conjunctival sac; ye dropper 1 to 2 cm (0.4 to 0.8 in) from the lower conjunctival sac

A nurse is caring for a client who has an NG tube for intermittent enteral feedings. Which of the following actions should the nurse take?

Elevate the client's head of bed 45 degree before the feeding; The nurse should flush the tubing with at least 30 mL of water after the enteral feeding to maintain patency of the feeding tube.; The nurse should auscultate for bowel sounds before each feeding to ensure the client has peristalsis bowel activity for the digestive system to digest or absorb the enteral nutrition.

A nurse is performing eye irrigation for a client who was exposed to smoke and ash. Which of the following actions should the nurse take?

Exert pressure on the bony prominences when holding the eyelids open; The nurse should hold the upper lid against the eyebrow and the lower lid against the cheekbone when irrigating the eye.

A nurse is preparing to insert an NG tube for a client who has a bowel obstruction. Which of the following actions should the nurse take first?

Explain the procedure to the client

A nurse is caring for a client who has a hearing impairment. Which of the following interventions should the nurse use when speaking with the client?

Face the client when speaking

A nurse is providing teaching to a group of unit nurses about wound healing by secondary intention. Which of the following information should the nurse include in the teaching?

Granulation tissue fills the wound during healing

A nurse is teaching a client who is recovering from gallbladder surgery how to use an incentive spirometer. Which of the following information should the nurse include in the teaching?

Hold breath for 5 seconds after goal volume is reached; This decreases the collapse of alveoli, which helps to prevent the risk of atelectasis and pneumonia.

A nurse is changing the bed linens for a client who is on bed rest. Which of the following actions should the nurse plan to take?

Hold the liens away from the body and clothing

A nurse is caring for a toddler at a well-child visit when the mother calls to the nurse, "Help! My baby is choking on his food." Which of the following findings indicates the toddler has an airway obstruction?

Inability of the toddler to cry or speak

A nurse is administering a cleansing enema to a client who is scheduled for a diagnostic procedure. Which of the following actions should the nurse take?

Insert the tip of the tubing 8 cm (3.1 in); 7 to 10 cm

A nurse is preparing to anchor with tape the catheter tube for a male client who has a newly inserted indwelling urinary catheter. At which of the following locations should the nurse tape the catheter?

Lower abdomen; or the upper aspect of the thigh to eliminate the penoscrotal angle and prevent tissue injury.

A nurse is changing the dressings for a client who has two Penrose drains near an abdominal incision. Which of the following adhering devices is the best choice for the nurse to use the decrease skin irritation?

Montgomery straps

A nurse is caring for an older adult client who has dysphagia following a cerebrovascular accident. Which of the following actions should the nurse take when assisting the client at mealtime?

Offer the client tart or sour foods first; to stimulate saliva production, which helps with chewing and swallowing.

A nurse is preparing to remove an NG tube for a client who has a partial colectomy. Which of the following actions should the nurse take?

Pinch the NG tube while removing the tube; to decrease the risk of aspiration of any gastric contents.

A nurse is planning to collect a stool specimen for ova and parasites from a client who has diarrhea. Which of the following actions should the nurse take when collection the specimen?

Place the stool specimen collection container in a biohazard bag; to prevent contamination with microorganisms.

A nurse is performing suctioning for a client who has a tracheostomy. Which of the following actions should the nurse take?

Pull suction catheter back 1 cm (0.5 in) if the client starts coughing; This will remove the catheter from the mucosal wall of the trachea prior to suctioning.

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?

Purulent exudate

A nurse is helping a client change his hospital gown. The client has an IV infusion on an infusion pump. Which of the following actions should the nurse take first?

Remove the sleeve of the gown from the arm without the IV line; enable the nurse to move the gown fully off the client and last stop the system to remove the gown off the line, resulting in minimal interruption of the IV flow.

A nurse is planning care for a client who is confused and requires a prescription for wrist restraints. Which of the following interventions should the nurse include in the plan of care?

Renew the prescription for the use of restrains within 24 hr

A nurse is caring for a client who has a history of dysrhythmias. Upon entering the room, the nurse discovers the client is unresponsive to verbal or painful stimuli, has no respiration, and is pulseless. Which of the following actions should the nurse take first?

Start chest compression

A nurse is caring for a client who is receiving an IV fluid replacement. Which of the following findings should the nurse identify as infiltration of the IV infusion site?

Taut skin around the IV catheter site that is cool to the touch; The nurse should stop the IV infusion, elevate the extremity, and apply a warm moist compress, or a cold compress according to the type of infiltration.

A nurse is preparing to administer an intramuscular injection to a client who is overweight. Which of the following sites should the nurse select for the injection?

The side hip between the iliac crest and anterior iliac spine; ventrogluteal injection and is preferred for adult client.

A nurse is applying antiembolitic stocking for a client who has a history of deep vein thrombosis. Which of the following actions should the nurse take when applying the stockings?

Turn the stocking inside out up the heel before applying

A nurse is preparing to assist with ambulation of an older adult client who was on bed rest for 3 days. Which of the following actions should the nurse take to decrease the risk of a fall?

Use a gait belt during ambulation; to keep the client's center of gravity midline and decrease the risk of a fall.

A nurse is planning to administer pain medication to a client who has pain following abdominal surgery. Which of the following actions should the nurse take first?

Use the pain scale to determine the client's pain level.

A nurse is planning care for a client who has a wound infection following abdominal surgery. To promote healing and fight infection, which of the following vitamins and minerals should the nurse plan to increase in the client's diet?

Vitamin C and zinc

A nurse is planning care for an adult client who has fluid volume excess. Which of the following interventions should the nurse plan to include to monitor the client's weight?

Weigh the client on arising; after voiding, and before breakfast; An increase of 1 kg (2.2 lb) is equal to 1,000 mL (1 L) of retained fluid.

A nurse is caring for a client who postoperative and who has an indwelling urinary catheter to gravity drainage. The nurse notes no urine output in the past 2 hr. Which of the following actions should the nurse take first?

Check to determine if the catheter tubing is kinked

A nurse is collecting a urine specimen for culture and sensitivity for a client who has urinary tract infection. The client has an indwelling urinary catheter in place. Which of the following actions should the nurse take?

Clamp the tubing below the collection port

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

Cleanse the skin around the stoma with warm water

A nurse is caring for a client who had a mastectomy and has self-suction drainage evacuator in place. Which of the following actions should the nurse take to ensure proper operation of the device?

Collapse the device of air after emptying; to create enough suction to pull fluid exudate into the collection area of the device.

A nurse is planning care for a client who has prescription for collection of a sputum specimen for culture and sensitivity. Which of the following actions should the nurse take when obtaining the specimen?

Collection the specimen upon arising in the morning

A nurse is performing a straight urinary catheterization for a female client who has urinary retention. Which of the following actions indicates the nurse is maintaining sterile technique?

Wipes the labia minora in an anteroposterior direction; both the right and left labia minora with separate cotton swabs to destroy any microorganisms in the area that would contaminate the catheter.