Fundamentals 2 Quiz

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

Wipes the labia minora in an anteroposterior direction

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 Purulent exudate drainage on the client's dressings is thick yellow, green and brown drainage and usually indicates wound sloughing or infection.

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 discussions 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

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 a self-suctioning 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 The nurse should collapse the device of air after emptying the contents periodically to create enough suction to pull fluid exudate into the collection area of the device.

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

Elevate the clients head of the bed 45 degrees before the feeding

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 The nurse should always directly face the client who has a hearing impairment and stand or sit at the same level to maximize communication. Many clients who are hearing impaired combine lip reading with their residual hearing when communicating.

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

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 linens away from the body and clothing The nurse should hold the linens away from the body and clothing to prevent soiling or the transfer of microorganisms. The microorganisms present on the nurse's clothing can expose other clients to microorganisms.

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) The client who has impaired pharyngeal swallowing should consume tart and sour foods at the beginning of the meal to stimulate saliva production, which helps with chewing and swallowing.

A nurse is preparing to remove an NG tube for a client who had 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 collecting the specimen?

Place the stool specimen collection container in a biohazard bag.

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

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 respirations, and is pulseless. Which of the following actions should the nurse take first?

Start chest compressions

A nurse is carin 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

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 When the client has no sound passing through the vocal cords, the nurse should identify a complete airway obstruction is evident. The nurse should use the Heimlich maneuver to dislodge whatever is obstructing the trachea.

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)

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 According to evidence-based practice, the nurse should first remove the gown from the client's arm without the IV line. Beginning this process will 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 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

A nurse is planning care for a client who has a would 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 (Multivitamin, mineral supplement of both, in addition to vitamin E to aid in skin and wound healing)

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 The nurse should apply the least invasive priority-setting framework when caring for this client. This framework assigns priority to nursing interventions that are least invasive to the client, as long as those interventions do not jeopardize client safety. The nurse should take interventions that are not invasive to the client before interventions that are invasive. This reduces the number of organisms introduced into the body, decreasing the number of facility-acquired infections. The first action the nurse should take is to inspect the tubing carefully, straightening out any kinks, and make certain that there are no dependent loops. A common reason a tube is not draining is that there is a kink in the tubing or that the client is lying on it.

A nurse is collecting a urine specimen for culture and sensitivity for a client who has a 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 The nurse should clamp the tubing below the collection port to allow fresh uncontaminated urine to collect before withdrawing the specimen through the port and placing it in a sterile specimen cup.

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

Don clean gloves to remove the old 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 The nurse should drop the eye medication in the lower conjunctival sac to avoid placing the drops on the cornea and causing damage.

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 applying antiembolitic stockings for a client who has a history of DVT. Which of the following actions should the nurse take when applying the stockings?

Turn the stockings inside out up to the heel before applying The nurse should turn the stocking inside out up to the client's heel to make the application of the stocking easier and cause less constrictive wrinkles.

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, before breakfast)

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 to decrease skin irritation?

Montgomery straps The nurse should apply the least restrictive priority-setting framework. This framework assigns priority to nursing interventions that are least restrictive to the client, as long as those interventions do not jeopardize client safety. Least restrictive interventions promote client safety without using restraints. The nurse should only use physical or chemical restraints when the safety of the client, staff, or others is at risk. The nurse should plan to use Montgomery straps to minimize irritation to the skin near the incisional area. Montgomery straps are adhesive strips applied to the skin on either side of the surgical wound. The adhesive strips have holes for using gauze to tie the dressing securely. When the dressing is changed, the ties are released, the dressing replaced, and the ties secured again without removing the adhesive strips.

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 The nurse should consider Maslow's hierarchy of needs, which includes five levels of priority when caring for this client. The first level consists of physiological needs; the second level consists of safety and security needs; the third level consists of love and belonging needs; the fourth level consists of personal achievement and self-esteem needs; and the fifth level consists of achieving full potential and the ability to problem solve and cope with life situations. When applying Maslow's hierarchy of needs priority-setting framework, the nurse should review physiological needs first. The nurse should then address the client's needs by following the remaining four hierarchal levels. It is important, however, for the nurse to consider all contributing client factors, as higher levels of the pyramid can compete with those at the lower levels, depending on the specific client situation. The fourth level of Maslow's hierarchy of needs includes usefulness, self-worth, and self-confidence in fulfilling self-esteem needs. Therefore, to meet the client's physiological needs, the first action the nurse should take is to begin pain management by asking the client to describe her pain.

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 (least invasive)

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"

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 The nurse should report to the provider when the client has a ring of erythema (redness) on the surrounding skin, which might indicate underlying infection. This and any other manifestation of infection, such as purulent drainage, swelling, warmth, or a strong odor, should be reported to the provider.

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 clients perineum Caring for this client requires application of the nursing process priority-setting framework. The nurse can use the nursing process to plan client care and prioritize nursing actions. Each step of the nursing process builds on the previous step, beginning with assessment or data collection. Before the nurse can formulate a plan of action, implement a nursing intervention, or notify a provider of a change in the client's status, she must first collect adequate data from the client. Assessing or collecting additional data will provide the nurse with knowledge to make an appropriate decision. The priority nursing action is for the nurse to collect more data by assessing the area of irritation.

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

Collect the specimen upon arising in the morning The nurse should plan to collect the sputum specimen when the client arises in the morning because the client is able to more easily cough up the secretions that have accumulated during the night. Generally, the deepest specimens are obtained in the early morning, and it is preferable to collect the specimen before breakfast. The nurse should instruct the client to rinse the mouth, take a deep breath, and cough prior to expectorating into the sterile container.

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 upper aspect of the thigh to eliminate the penoscrotal angle and prevent tissue injury)

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 The side hip between the iliac crest and anterior iliac spine forms the boundaries for ventrogluteal injection; therefore, this is an appropriate site for the nurse to select. This site is the preferred site for intramuscular injections for an adult client. The nurse should prepare for injection by placing a hand on the client's greater trochanter (right hand on left hip, for example) with the first two fingers touching the iliac crest and anterior superior iliac spine, forming a "V" shape.