fundamentals final
The client is admitted with left lower leg pain, a positive Homans' sign, and a temperature of 100.4° F (38° C). The nurse should assess the client further for signs of:
deep vein thrombosis (DVT) in the left leg.
A mother asks the nurse how to handle her 4-year-old child, who recently started wetting the pants after being completely toilet-trained. The child just started attending nursery school 2 days per week. Which statement by the mother indicates understanding of the situation?
"My child is most likely regressing back to a behavior that increases his sense of security."
When preparing a client with acquired immunodeficiency syndrome (AIDS) for discharge to home, the nurse should be sure to include which instruction?
"Avoid sharing such articles as toothbrushes and razors."
The health care provider has prescribed penicillin for a client admitted to the hospital for treatment of pneumonia. Prior to administering the first dose of penicillin, the nurse should ask the client:
"Have you had a previous allergy to penicillin?"
A pregnant client asks how she can best prepare her 3-year-old son for the upcoming birth of a sibling. The nurse should make which suggestion?
"Involve your son in planning and preparing for a sibling."
The physician orders 250 mg of a drug. The drug vial reads 500 mg/ml. How much of the drug should the nurse give?
1/2 ml
A nurse is to give a client an I.V. infusion of 3,000 ml of dextrose and normal saline solution over 24 hours. She observes that the infusion rate is 150 ml/hour. If the solution runs continuously at this rate, the infusion will be completed in:
20 hours.
The nurse is preparing to administer IM morphine sulfate to a client who is in pain. On checking the health care provider's (HCP's) prescription, the nurse notes that the prescription states, "morphine sulfate 60 mg IM every 4 hours as needed for pain." The usual dose of morphine is 10 to 15 mg. What is the most appropriate action for the nurse to take?
Contact the HCP to verify the prescription.
Furosemide 40 mg intravenous push (IVP) is prescribed. Furosemide 10 mg/mL is available. How many mL should the nurse should administer? Record your answer using a whole number.
4
A multiparous client and her neonate, who has been cared for in the intensive care nursery for the past 3 days because of being small for gestational age, are to be discharged. Before their release, the mother tells the nurse, "I have been living in my car for the past 2 weeks." What should the nurse do next?
Contact the hospital's social worker.
Levothyroxine 0.2 mg orally has been ordered for a client diagnosed with hypothyroidism. The nurse has available 0.05-mg tablets. How many tablets should the nurse prepare to give the client?
4 tablets.
A toddler develops acute otitis media and is ordered cefpodoxime proxetil 5 mg/kg P.O. every 12 hours. If the child weighs 22 lb (10 kg), how many milligrams will the nurse administer with each dose?
50 mg
When giving an I.M. injection, the nurse should insert the needle into the muscle at an angle of:
90 degrees
A client on the palliative unit discusses treatment with the nurse. The client wants to refuse further chemotherapy and request pain management strategies only. What is the most appropriate action by the nurse in relation to the client's requests?
Acknowledge the client's right to make the choices regarding treatment.
A nurse is preparing to administer a sustained-release capsule to a client. Which is an appropriate nursing intervention?
Administering the capsule whole with a glass of water
After a car accident, a child, age 10, is treated in the emergency department for a fractured clavicle and evaluated for a possible head injury. Alert and oriented, she keeps asking what will happen to her. Which nursing diagnosis is most appropriate?
Anxiety related to separation from parents and an unfamiliar environment
The nurse gives a client 0.25 mg of digoxin instead of the prescribed dose of 0.125 mg. What action should the nurse take after realizing the mistake?
Assess the client and notify the physician.
A client is admitted to the health care facility with bowel obstruction secondary to colon cancer. The nurse obtains a health history, measures vital signs, and auscultates for bowel sounds. Which step of the nursing process is she performing?
Assessment
A nurse and a nursing assistant are caring for a group of adolescents. Which task could the nurse safely delegate to the nursing assistant?
Assisting an adolescent diagnosed with paraplegia with a meal
A nurse has been teaching a client about a high-protein diet. The teaching is successful if the client identifies which meal as high in protein?
Baked beans, hamburger, and milk
A nurse is assessing a postoperative client. Which information should the nurse document as subjective data?
Client's descriptions of pain
A client with septic shock has continued to deteriorate and has become unresponsive. The nurse has inserted an intravenous line and an oral airway. Which of the following is the highest priority for the nurse at this time?
Confirm the placement of the oral airway.
A client on prolonged bed rest has developed a pressure ulcer. The wound shows no signs of healing even though the client has received skin care and has been turned every 2 hours. Which factor is most likely responsible for the failure to heal?
Inadequate protein intake
Which clinical signs would indicate to a nurse caring for a terminally ill client that death may be imminent?
Diminished urine output and Cheyne-Stokes respirations
A school-age child begins to have a seizure while walking to the bathroom. What should the nurse do first?
Ease the child to the floor and turn him on his side.
The parent of a preschooler reports that the child creates a scene every night at bedtime. What is the best course of action?
Establish a set bedtime and follow a routine.
The nurse is caring for an infant with severe diarrhea that has lasted 3 days. The child has poor skin turgor and dry mucous membranes. What is the priority nursing diagnosis for the nurse to use when planning care for this child?
Fluid volume deficit
Which of the following would be best to help prepare a preschool-aged child for an injection?
Giving the child a play syringe and a bandage to give a doll injections.
A full-term neonate is admitted to the normal newborn nursery. When lifting the baby out of the crib the nurse notes the baby's arms move sideways with the palms up and the thumbs flexed. What should the nurse do next?
Identify this reflex as a normal finding.
When performing an assessment, the nurse identifies the following signs and symptoms: discoordination, decreased muscle strength, limited range of motion, and reluctance to move. These signs and symptoms indicate which nursing diagnosis?
Impaired physical mobility
A nurse finds that a colleague is intoxicated while on duty. What appropriate action should the nurse take?
Inform the nursing supervisor.
Which activity should a nurse recommend to prevent foreign body aspiration in a child during meals?
Insist that the child remain seated while eating.
The nurse evaluates the client's ability to instill eyedrops correctly. The client correctly demonstrates the procedure when the client:
Instills the eyedrops into the conjunctival sac.
A nurse is delivering a client's 10 a.m. (1000) medications. The client is away from his room for a diagnostic study. Which action is most appropriate for the nurse to take?
Lock the medications in the medicine cabinet until the client returns.
Which point should a nurse include when teaching mothers about preventing childhood falls?
Never leave the infant alone on an elevated surface.
To evaluate a client's reason for seeking care, a nurse performs deep palpation. What is the nurse assessing?
Organs
A staff nurse on the oncology unit must teach the new unit assistant about infection control practices. The nurse should explain that which measure is most important for preventing the spread of infection?
Performing proper hand hygiene
For a child with hemophilia, what is the most important nursing goal?
Preventing bleeding episodes
Which sentence correctly describes the prone position?
The body is facedown.
A nurse is concerned about another nurse's relationship with the members of a family and their ill preschooler. Which behavior should be brought to the attention of the nurse-manager?
The nurse attempts to influence the family's decisions by presenting her own thoughts and opinions.
A client with terminal breast cancer is being cared for by a long-time friend who's a physician. The client has identified her sister as the agent in her health care power of attorney. The client loses decision-making capacity, and the sister tells the nurse, "A different physician will be caring for my sister now. I've dismissed her friend." In response, the nurse should:
abide by the wishes of the sister who holds the durable power of attorney.
Which meal would be most appropriate for a 15-year-old with glomerulonephritis with severe hypertension?
baked chicken, rice, beans, orange juice
Which nursing action is most important in preventing cross-contamination?
changing gloves immediately after use
A nurse is caring for a client in a vegetative state following a traumatic head injury. During the initial assessment, the nurse notes that the client has difficulty digesting a new tube feeding formula. When she contacts the dietician to discuss the change in the tube-feeding formula, the nurse is demonstrating the nursing role of:
client advocate.
A client is admitted with fatigue, shortness of breath, pale skin, and dried, cracked lips, tongue, and mouth. The hemoglobin is 9 g/dL (90 g/L), and red blood cell count is 3.5 million cells/mm3 (3.5 × 1012/L). The nurse should instruct the client to:
eat foods with good sources of iron.
The client has just had a total knee replacement for severe osteoarthritis. When assessing the client, which finding should lead the nurse to suspect possible nerve damage?
numbness
The best indicator that the client has learned how to give an insulin self-injection correctly is when the client can:
perform the procedure safely and correctly.
When developing the plan of care for a client with suicidal ideation, developing goals to address which issue is a priority?
safety
A nurse is planning a health teaching session for a group of parents with toddlers. When describing a toddler's typical eating pattern, the nurse should mention that many children of this age exhibit:
strong food preferences.
When the client is involuntarily committed to a hospital because he is assessed as being dangerous to himself or others, which client rights are lost?
the right to leave the hospital against medical advice
To calculate drug dosages for a 4-year-old child, the physician might use a formula that involves the child's:
weight in kilograms.
A physician orders heparin, 7,500 units, to be administered subcutaneously every 12 hours. The vial reads 10,000 units per milliliter. The nurse should anticipate giving how much heparin for each dose?
¾ ml
The nurse is instructing a client on a tyramine-free diet. Which dietary selection by the client requires further discussion?
Aged cheese, Chianti wine, and garlic bread
A nurse inadvertently transcribes a client's medication order that was written as "Ampicillin 250 mg four times a day" as "Ampicillin 2500 mg four times a day." The nurse gives two doses as transcribed to the client. Another nurse gives one dose before the pharmacist questions the reorder of the medication. What should the two nurses do in this situation?
Both nurses must acknowledge making the medication error.
An elderly client with Alzheimer's disease has been living with his grown child's family for the past 6 months. He wanders at night and needs help with activities of daily living. Which statement by his child suggests that the family is successfully adjusting to this living arrangement?
"Dad has presented many challenges. We have alarms on all the outside doors now. Respite care gives us a break."
A client asks the nurse why taking folic acid is so important before and during pregnancy. The nurse should instruct the client that:
"Folic acid is important in preventing neural tube defects in newborns and preventing anemia in mothers."
A client with depression who is taking doxepin 100 mg P.O. at bedtime has dizziness on arising. Which of the following suggestions is most appropriate?
"Get up slowly and dangle your feet before standing."
A nurse is caring for a client who has had a massive stroke. The family communicates concern about the actions of the nurse on the previous shift. The family reports that the nurse didn't administer medications properly or maintain client privacy. When responding to complaints about a colleague, the nurse should say:
"I'd be happy to get the charge nurse to see what we can do for the client."
A nurse is teaching a parent how to administer antibiotics at home to a toddler with acute otitis media. Which statement by the parent indicates that teaching has been successful?
"I'll give the antibiotics for the full 10-day course of treatment."
A client who is about to undergo gastric bypass surgery calls the nurse into the room. The client whispers to the nurse her concern that friends will learn about her upcoming surgery. She pleads with the nurse to keep her surgery a secret. Which response by the nurse is best?
"I'm not at liberty to discuss your case with anyone except those directly involved in your care, unless you authorize me to do so."
A nurse is performing discharge teaching for an elderly client diagnosed with osteoporosis. Which statement about home safety should the nurse include?
"Most falls among the elderly occur in the home. These clients should remove throw rugs and install bathroom grab bars."
After teaching the parents of a child with lactose intolerance about the disorder, the nurse determines that the teaching was effective when the mother used which statement to describe the condition?
"The lack of an enzyme to break down lactose."
At a well-baby visit, a mother expresses frustration about her 3-year-old child always crying when she drops the child off at day care. She states that the child clings to her and doesn't want her to leave, but seems happy when she picks the child up later in the day. What is the best advice the nurse can give the mother?
"This is a normal stage of development that toddlers go through."
An agitated client demands to see her chart so she can read what has been written about her. Which statement is the nurse's best response to the client?
"You have the right to see your chart. Please discuss your wish with your physician."
Which of the following nursing actions would be most beneficial to a client and her husband who state they wish to go through labor without the use of analgesics or anesthetic agents?
Act as an advocate for the couple and verbalize their wishes to nurses and physicians.
A nurse is preparing to teach a 13-year-old adolescent with asthma to administer his own breathing treatments. Which principle should the nurse keep in mind when planning the teaching session?
Adolescents are worried about appearing different from their peers.
A client at 12 weeks' gestation tells the nurse that she is a vegetarian and eats "lots of rice." To help meet the client's need for protein during pregnancy, the nurse suggests that the client combine the rice with which of the following?
Beans
A nurse working on a new unit is required to administer an unfamiliar medication to a client. How should the nurse proceed with the medication administration?
Consult a formulary or drug handbook to learn about the medication.
To help prevent osteoporosis, what should a nurse advise a young woman to do?
Consume at least 1,000 mg of calcium daily.
A nurse is working in a group home for children with cognitive impairments. The nurse has a heavy assignment and has fallen behind on medication administration. The unregulated care provider (UCP) offers to help the nurse finish administering the medications. What is the correct action for the nurse to take?
Delegate appropriate tasks to the UCP and finish the medication administration.
The nurse is caring for two children in the same room. The parents of one child ask the nurse about the condition of the other child. What is the most appropriate response by the nurse?
Explain that giving information would violate confidentiality.
Which action demonstrates a safe response plan in the event of fire?
Implement the RACE plan.
A hospitalized client with a fracture of the tibia and fibula of the left leg is reporting increased pain at the site. What signs must the nurse be alert to that would indicate compromised circulation to the leg?
Increased swelling of the toes and decreased distal pulses
Which nursing diagnosis is the most appropriate for a preschool child with epiglottiditis?
Ineffective airway clearance related to laryngospasm
The nurse is assessing the neurovascular status of a client's right arm, which has just had a cast applied. The nurse should notify the physician about which of the following?
Nail bed capillary refill time of 10 seconds.
A healthcare provider obtains informed consent for a surgical procedure after the adult client had received sedation. Which is the nurse's best action?
Notify the healthcare provider that the consent is not valid
The nurse has been teaching the client about maintaining a high-fiber diet. The client's selection of which of the following breakfast menus indicates an understanding of the instructions?
Oatmeal, milk, grapefruit wedges, and bran muffin.
Which of the following techniques is best for the nurse to use in evaluating the parents' ability to administer eardrops correctly?
Observe the parents instilling the drops in the child's ear.
During a well-baby visit, a mother asks the nurse when she should start giving her infant solid foods. The nurse should instruct her to introduce which solid food first?
Rice cereal
When administering medication, the nurse ensures client safety by following the rights of medication administration. Identify the "rights of medication administration." Select all that apply.
Right client Right dose Right medication Right time Right route
A nurse is conducting a nutrition class for a group of teenagers. Which of the following food choices would a nurse encourage this group to consume to increase their dietary fiber content?
Sandwiches on whole wheat bread
When developing a teaching plan for a client who is 8 weeks pregnant, which of the following foods would the nurse suggest to meet the client's need for increased folic acid?
Spinach
A client receiving morphine for long-term pain management develops tolerance. Tolerance is defined as:
a diminished response to a drug so that more medication is required to achieve the same effect.
A client newly diagnosed with tuberculosis (TB) is being admitted with a prescription for "isolation precautions for tuberculosis." The nurse should assign the client to which type of room?
a private room to implement airborne precautions
A nurse prepares to administer medication by the buccal route. Where should the nurse place this medication?
between the client's cheek and gum
A nurse on a rehabilitation unit is caring for a client who sustained a head injury in a motor vehicle accident. She notes that the client has become restless and agitated during therapy; previous documentation described the client as cooperative during therapy sessions. The nurse's priority action should be to:
gather assessment data and notify the physician of the change in the client's status.
An elderly client with a diagnosis of chronic renal failure is being discharged to home with his wife. The home health nurse visits the hospital before discharge to discuss home safety with the client, who reports decreased mobility and a need for greater assistance with activities of daily living. The nurse focuses her home-safety teaching on:
having adequate lighting, removing cluttered paths, and using nonskid bathroom surfaces.
Nursing staff are trying to provide for the safety of an elderly client with moderate dementia. The client is wandering at night and has trouble keeping her balance. She has fallen twice but has had no resulting injuries. The nurse should:
move the client to a room near the nurse's station and install a bed alarm.
A nurse is teaching a group of nursing assistants about infection-control measures. The nurse tells the group that the first line of intervention for preventing the spread of infection is:
washing hands
When teaching school-age children important injury prevention strategies, the nurse must use creativity to gain cooperation because children tend not to comply with:
wearing safety apparel (helmets, knee pads, elbow pads).
A public health nurse is responsible for contact tracing of individuals identified in confirmed cases of sexually transmitted infections. The nurse telephones an individual named by a client as a contact. The individual demands the name of the person who identified the individual as a contact. Which of the following is the most appropriate response from the nurse?
"Just as I will protect your privacy, I must protect the privacy of the other people involved."
A worried mother confides in the nurse that she wants to change primaryhealth care providers (HCP's) because her infant is not getting better. What is the nurse's best response?
"You always have an option to change. Tell me about your concerns."
A nurse observes a consent form signed by a client indicating permission for the insertion of a feeding tube before the beginning of chemotherapy. One hour before the procedure, the client states, "I have changed my mind and now do not want the feeding tube." What would be the most appropriate response by the nurse?
"You have a right to withdraw consent, so let's discuss your decision."
The physician orders 2 teaspoons of an oral laxative as needed for a constipated client. How many milliliters should the nurse administer to the client?
10
The physician prescribes bupropion, 150 mg by mouth twice per day to treat symptoms of depression. The nurse has 75-mg tablets on hand. How many tablets should the nurse administer with each dose? Record your answer using a whole number.
2
The client is to undergo a series of diagnostic tests to determine if the client's cognitive impairment is treatable. Which of the following states can lead to nonreversible cognitive impairment?
Alzheimer's disease.
A nurse manager is auditing the nursing unit's adherence to infection control practices. Which of the following observations causes the nurse manager to be most concerned that the clients on the unit are at risk for infection?
Hand hygiene is forgotten between clients by several nurses on the unit.
A client is voluntarily admitted to a substance abuse unit. He admits to drinking at least 1 qt of vodka each day and occasionally using cocaine. Several hours after admission, a nurse suspects that the client is likely experiencing early alcohol withdrawal. What assessment findings support the nurse's suspicions?
Pulse rate of 135 beats/minute, tremors, and nervousness
A nurse is preparing to perform complex abdominal wound care. Which action should the nurse take while performing this task?
Raise the bed to approximately waist level.
During labor, a client greatly relies on her partner for support. They previously attended childbirth education classes, and now he's working with her on comfort measures. Which nursing diagnosis is appropriate for this couple?
Readiness for enhanced family coping related to participation in pregnancy and delivery
A nurse is caring for a client with bulimia nervosa. Strict management of the client's dietary intake is necessary. Which intervention is the most important?
Serve the client's menu choices in a supervised area and observe her 1 hour after each meal.
