Fundamentals 2

A nurse is explaining the use of written consent forms to a newly licensed nurse. The nurse should ensure that a written consent form has been signed by which of the following clients? A. A client who has a prescription for a transfusion of packed red blood cells B. A client who is being transported for a radiograph of the kidneys, ureters, and bladder C. A client who has a prescription for TB skin test D. A client who has a distended bladder and needs urinary catheterization

A. A client who has a prescription for a transfusion of paced red blood cells

A newly licensed nurse is preparing to adminster meds to a client. The nurse notes that the provider has prescribed a medication that is unfamiliar to him. Which of the following actions should the nurse take? A. Consult the med reference book available on the unit B. Ask a more experienced nurse for info about the med C. Call the clients provider and verify the prescription D. Ask the client if she takes the med at home

A. Consult the med reference book available on the unit

A nurse is caring for a client who is post op following abdominal surgery. Which of the following actions should the nurse perform first after discovering that the clients wound has eviscerated? A. Cover the incision with a moist sterile dressing B. Have the client lie on his back with his knees flexed C. Call the clients surgeon D. Reassure the client

A. Cover the incision with a moist sterile dressing

A nurse is preparing to administer meds to a client who has gout. The nurse discovers that an error was made during the previous shift in which the client received atenolol instead of allopurinol. Which of the following interventions is the nurse's priority? A. measure the clients apical pulse B. Administer the allopurinol to the client C. Inform the nurse manager D. Complete an incident report

A. Measure the clients apical pulse

A nurse is preparing to provide chest physiotherapy for a client who has left lower lobe atelectasis. Which of the following actions should the nurse plan to take? A. Place the client in the Trendelenburg position B. Perform percussions directly over the clients bare skin C. Use flattened hand to perform percussions D. Remind the client that the chest percussions can cause mild pain

A. Place the client in the Trendelenburg position

A nurse is performing suctioning for a client who has a tracheostomy. Which of the following actions should the nruse take? A. Pull the suction catheter back 1cm if the client starts coughing B. Allow 30 sec between suctioning passes C. Hyperventilate the client with 50% oxygen for 30 sec D. Perform a maximum of 4 passes with the suction catheter

A. Pull suction catheter back 1 cm if the client starts coughing

A nurse is helping a client change his hospital gown. The client has an IV infusion via an infusion pump. Which of the following actions should the nurse take first? A. Remove the sleeve of the gown from the arm without the IV line B. Slow the infusion using the roller clamp C. Disconnect the IV line from the pump D. Bring the IV solution and tubing from the outside to the inside of the sleeve of the gown

A. Remove the sleeve of the gown from the arm without the IV line

A nurse is preparing to administer a unit of packed RBC's to a client. Which of the following pieces of info must the nurse verify with another nurse prior to administration? SATA A. The clients ID number B. The clients room number C. The clients name D. ABO compatibility E. Rh compatibility

A. the clients id number C. The clients name D. ABO compatibility E. RH compatibility

A nurse is caring for a client who is receiving total parental nutrition (TPN). Which of the followin actions should the nurse take? A. Administer 0.9% sodium chloride until TPN is available form the pharmacy B. Check the clients capillary blood glucose level every 4 hours C. Obtain the clients weight each week D. Change the IV tubing every 3 days

B. Check the clients capillary blood glucose level every 4 hour

A nurse is collecting a specimen for culture from a clients infected wound. Which of the following actions should the nurse perform? A. Wear sterile gloves when collecting the specimen B. Cleanse the wound with 0.9% sodium chloride irrigation C. Allow the collection swab to absorb the old exudate D. Rotate the collection swab over the edges of the wound

B. Cleans the wound with 0.9 sodium chloride irrigation

A nurse is monitoring a cilents lab results. Which of the following results hsould the nurse report to the provider? A. Sodium 140 B. K 3.0 C. Chloride 100 D. Mg 2.0

B. K 3.0

A nurse on a med surg unit is caring for a client. Which of the following actions should the nurse prioritize when using the nursing process? A. Identify goals for client care B. Obtain client information C. Document nursing care needs D. Evaluate the effectiveness of care

B. Obtain client informatoin

A nurse is caring for an older adult client who has dysphagia following a cebreovascular accident. Which of the following actions should the nurse take when assisting the client at mealtime? A. Encourage the client to drink fluids before swallowing food B. Offer the client tart or sour foods first C. Tilt the clients head backward when swallowing D. Turn on the television

B. Offer the client tart or sour foods first

A nurse is caring for a client in a long term care facility. Which of the following findings should alert the nruse to the possibility that the client has developed delirium? A. Gradual memory loss B. Reduced level of consciousness C. Difficulty with abstract thought D. Verbalized feelings of hopelessness

B. Reduced level of consciousness

A nurse is demonstrating postop deep breathing and coughing exercises to a client who is scheduled for emergency surgery for appendicitis. Which of the following statements indicates a lack of readiness to learn by the client? A. The client asks the nurse to repeat the instructions before attempting the exercises B. The client reports severe pain C. The client asks the nurse how often breathing should be done after surgery D. The client tells the nurse that this exercise will probably be painful after surgery

B. The client reports severe pain

A nurse is preparing to administer eye drops for a client who has glaucoma. When instilling the medication, which of the following actions should the nurse take? A. Instruct the client to blink several times after instilling the medication B. Ask the client to look straight ahead during instillation of the medication C. apply pressure to the puncta after instilling the med D. place each drop of the med directly into the cornea

C. Apply pressure to the puncta after instilling the med

A nurse is teaching a client with lower extremity weakness how to use a 4 point crutch gate. Which of the following instructions should the nurse include in the teaching? A. support the majority of your weight on the axillae B. Keep your elbows extended C. Bear weight on both of your legs D. Move both crutches forward at the same time

C. Bear weight on both of your legs

A nurse is caring for a client who requires a peripheral IV insertion. When choosing the site, which of the following sites should the nurse select? A. Select a vein in the clients dominant arm B. Choose the most proximal vein in the extremity C. Choose a vein that is soft on palpation D. Select a site distal to previous venipuncture attemps

C. Choose a vein that is soft on palpation

A nurse is assessing a client who has a total calcium level of 12.7 mg/dl. Which of the following findings should the nurse expect? A. Muscle tremors B. Postive Chvostek's sign C. Depressed deep tendon reflexes D. Numbness around the mouth

C. Depressed deep tendon flexes

A nurse is working with the faculty's language interpreter to explain a wound care procedure to a client who does not speak the same language as the nurse. Which of the following actoins should the nurse take when describing the procedure to the client? A. Make eye contact with the interpreter B. Break sentences into shorter segments to allow time for interpretation C. Ensure the interpreter and the client speak the same dialect D. Speak in a loud town of voice

C. Ensure the interpreter and the client speak the same dialect

A nurse is performing eye irrigation for a client who was exposed to smoke and ash. Which of the following actions shouldn't he nurse take? A. Hold the irrigator 1.25 cm above the eye B. Direct the irrigation solution up toward the upper eyelid C. Exert pressure on the bony prominences when holding the eyelids open D. Direct the irrigation from the outer canthus to the inner canthus of the eye

C. Exert pressure on the bony prominences when holding the eyelids open

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? A. Give the client a glass of water B. Assist the client into a sitting position C. Explain the procedure to the client D. Measure the length of tubing to be inserted

C. Explain the procedure to the client

A nurse is teaching a middle-aged female client about disease prevention and health maintenance. Which of the following diagnostic tests should the nurse recommend as part of this clients routine health screening? A. Annual Papanicolaou screening B. Mammogram every 2 years C. Eye exam every 2 years D. Annual colonoscopy.

C. Eye exam every 2years

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? A. Lubricate up to 3.2 cm (1.25 in) of the tip of the rectal tube B. Position the client on the right side C. Insert the tip of the tubing 8cm (3.1 in) D. Hold the enema container 61 cm (24 in) above the rectum

C. Insert the tip of the tubing 8 cm

A nurse is performing an admission assessment for a client. Which of the following responses by the nurse reflects the communication technique of clarifying? A. Now that we have talked about your medications, lets talk about your pain B. Are you having any other symptoms? C. It sounds like your pain is intermittent D. It seems as though you have really had a rough time these past few weeks

C. It sounds like your pain is intermittent

A nurse is assessing a clients thyroid gland. Which of the following instructions should the nurse give the client before inspecting and palpating this gland? A. Tilt your head slightly forward B. Keep your head straight and look ahead of you C. Tilt your head back and swallow D. Turn your head to the side against my hand

C. Tilt your head back and swallow

A nurse is caring for a client who has xerostomia with a lack of saliva. Which of the following nutrients will be affected by the lack of salivary amylase? A. Fat B. protein C. startch D. fiber

C. starch

A nurse is a providers office is assessing a client who has heart failure. The client has gained weight since her last visit, and her ankles are edematous. Which of the following findings is another clinical manifestation of fluid volume excess? A. sunken eyeballs B. hypotension C. poor skin turgor D. Bounding pulse

D. Bounding pulse

A nurse is preparing to administer a TB skin test to a client. After performing hand hygiene, which of the following actions should the nurse take? A. select a 23 gauge needle B. Insert the needle into the skin at a 25 degree angle C. Massage the area of injection following the removal of the needle D. Circle the injection area with a pen

D. Circle the injection area with a pen

While admitting a client to the medical unit, the nurse asks him if he has advanced directives. The client states, "I have a document with me that names someone who can make health care decisions for me if i am not able". the nurse should identify that the client is referring to which of the following documents? A. informed consent form B. Living will document C. DNR directive D. Durable power of attorney document

D. Durable power of attorney document

A nurse is caring for a client who is postop 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 towards the wound D. From the wound toward the surrounding skin

D. From the wound toward the surrounding skin

A nurse is changing the dressings for a client who has 2 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? A. Abdominal binder B. Montgomery straps C. Hypoallergenic tape D. Plastic tape

B. montomery tape

A nurse is admitting a client who has measles. Which of the following types of transmission precautions should the nurse initiate? A. Airborne B. Droplet C. Contact D. Protective environment

A. Airborne

A nurse is planning weight loss strategies for a group of clients who are obese. Which of the following actions by the nurse will improve the clients commitment to a long term goal of weight loss? A. Attempt to increase the clients self motivation B. Keep detailed records of each clients progress C. Test the client learning after each teaching lesson D. Avoid discussion topics that might increase clients anxiety

A. Attempt to increase the clients self motivation

A nurse is responding to a parents question about his infants expected physical development during the first year of life. Which of the following pieces of information should the nurse include? A. A 2 month old infant can turn from his abdomen to his back B. A 10 month old infant can pull up to a standing position C. A 4 month old infant can sit up without support D. A 6 month old infant can crawl on his hands and knees

B. A 10 month old infant can turn from his abdomen to his back

A nurse is teaching a client who is post op following a knee arthroplasty about the muscles he will need to strengthen in physical therapy. Which of the following muscle groups is responsible for movement at the knee joint? A. Antigravity B. Antagonistic C. Synergistic D. Skeletal

B. Antagonistic

A nurse is caring for a client who reports feeling a pop after coughing without properly splinting an abdominal incision. On assessment, the nurse notes that the clients wound has eviscerated. Which of the following actions should the nurse take? SATA A. Carefully reinsert the intestine through the opening of the wound B. Place the client in a supine position with the hips and knees flexed C. Leave the room to call the surgeon D. Cover the wound and intestine with a sterile, moistened dressing E. Monitor the client for manifestations of shock

BDE

A nurse is talking with a parent of a preschool aged child who tells the nurse "my child has suddenly become disinterested in certain foods" which of the following statements should the nurse make? A. During this phase, feed your child anything she will eat B. Increase the amount of calories and water you child consumes c. Keep a diary of the foods your child eats each day D. Provide a large variety of fruit juices for your child to choose from

C. Keep a diary of the food your child eats each day

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? A. Maintain suction while removing the NG tube B. Instill 100ml of air into the ng tube before removal C. Pinch the NG tube while removing the tube D. Instruct the client to breathe in and out during the removal of the NG tube

C. Pinch the NG tube while removing the tube

A nurse is caring for a client who is recieving intermittent enteral feedings through an NG tube. The specific gravity of the clients urine is 1.035. Which of the following actions should the nurse take? A. Deliver the formula at a slower rate B. Request a lower fat formula C. Provide more water with feedings D. Instill a lactose free formula

C. Provide more water with feedings

A nurse is examining a client for signs of costovertebral angle tenderness. The nurse should place the client in which of the following positions for evaluation. A. sims B. Supine C. sitting D. Standing

C. Sitting

A nurse is caring for a client who has major fecal incontinence and reports incontinence and reports irritation in the perianal area. Which of the following actions should the nurse take first? A. Apply fecal collection system B. Apply barrier cream C. Cleanse and dry the area D. Check the clients perineum

D. Check the clients perineium

A nurse is planning to insert a NG tube for a client after explaining the procedure. The client states, "you are not putting that hose down my throat". Which of the following statements should the nurse make? A. Lets get the process over with because you won't get better without this tube B. You should talk to your provider about your fears C. Why dont you want the tube inserted? D. I can see that this is upsetting you

D. I can see that this is upsetting you

A nurse is teaching a client who is using a PCA pump to deliver morphine for pain management. Which of the following statements should the nurse identify as an indication that the client understands the instructions? A. I'll limit pushing the button so I dont get an overdose B. If I push the button and still have pain after 2 minutes, I'll push it agian C. I'll ask the niece to push the button when i am sleeping D. I can still use my transcutaneous electrical nerve stimulation unit while I'm pushing the PCA button

D. I can still use my transcutaneous unit while I'm pushing the PCA button

A nurse is planning care for a client who has anorexia and nausea due to cancer treatment. Which of the following interventions should teh nurse include? A. Serve foods at warm or hot temperatures B. Offer the client low-density foods C. Make sure the client lies supine after meals D. Limit drinking liquids with foods

D. Limit drinking liquids with food

A nurse has received a prescription for dextran to administer to a client. the nurse should recognize that dextran belongs in which of the following functional classifications? A. Skeletal muscle relaxants B. Beta-adrenergic blockers C. Broad spectrum anti infective agents D. Plasma volume expanders

D. Plasma volume expanders

A nurse is caring for a client who requires wrist restraints. Which of the following actions should the nurse take? A. Tie a secure not with the restraint straps B. Attach the restraints to the bedside rails C. Make sure 3 fingers fit beneath ther restraints D. Remove the restraints at least every 2hours

D. Remove the restraints at least every 2 hours

A nurse is preparing to administer an afternoon dose of ampicillin to a client. The client appears upset and refuses to take the medication before throwing the pill on the floor. Which of the following entries should the nurse enter into the clients medical record? A. The client refused to take medication today B. The client stated, I will not take this pill C. The client seemed angry and hostile D. The client threw the medication on the floor

D. The client threw the medication on the floor

A nurse is witnessing a client sign an informed consent form for surgery. What is the nurse affirming by this action? A. The client fully understands the providers explanation of the procedure B. The client has been informed about the risks and benefits of the procedure C. The nurse witnessed the providers explanation of the procedure D. The signature of the prop consent form is the clients

D. The signature of the pre op consent form is the clients