fundamentals final exam

The nurse is caring for an adult patient with a temperature of 101.2° F. Which statement will the nurse make to the patient's family member who verbalizes concern over the patient's fever?

"Fevers under 102° F help the body's immune system fight infections."

The nurse suspects that the patient is experiencing a drug toxicity rather than a side effect. Which question will the nurse ask to help confirm this suspicion?

"Have you been taking extra doses of the medication?

Which statement made by the patient indicates readiness for learning about colostomy care?

"The sooner I can take care of it, the sooner I can go home."

A client with a history of cardiac disease is due for a morning dose of furosemide. Which serum potassium level, if noted in the client's laboratory report, would be reported before administering the dose of furosemide?

3.2 mEq/L (3.2 mmol/L)

Approximately how long is each cycle of sleep during a full night's sleep?

90 minutes

Which is an example of respite care?

A patient with dementia attends an adult day care center so that the patient's family can go to work.

How can the nurse best respect the patient's cultural preferences for hygiene?

Accommodate the patient's wish to wash before morning prayers.

The nurse administers the wrong dose of medication and then blames the mistake on a co-worker. Which ethical principle is violated by the nurse?

Accountability

The nurse is caring for a patient with arthritis who wants to exercise but finds it difficult due to joint pain and stiffness. Which nursing diagnosis is appropriate for this patient?

Activity intolerance related to exertional discomfort

The patient is nauseated and vomiting when the nurse attempts to provide discharge teaching. Which is the most appropriate action of the nurse?

Administer antinausea medication and provide discharge teaching later.

The nursing staff is caring for a patient who collapsed in cardiac arrest. When will breaths be delivered via the bag-valve mask device?

After every 30 chest compressions

The nurse is caring for a patient with a bacterial infection. After antibiotic treatment is started, the patient develops a generalized itchy rash. What is the most likely reason for the rash?

An allergic response to the prescribed medication

Which is an example of a tertiary health care provider?

An outpatient rehabilitation center

Which preoperative task may be delegated to the nursing assistant?

Apply the patient's thromboembolism deterrent (TED) stockings.

Which is the appropriate action for the nurse manager when a nurse refuses to assist with an abortion due to personal ethical beliefs?

Assign the nurse to care for other patients.

The nurse is caring for a patient who has shallow breaths following abdominal surgery. Which respiratory complication is most likely to occur as a result of the patient's breathing pattern?

Atelectasis

The nurse is caring for a patient who suddenly becomes acutely short of breath. The nurse elevates the head of the patient's bed, checks the patient's pulse oximetry, and administers 2 L of oxygen before notifying the patient's physician. Which term best describes the actions of the nurse?

Autonomy

Which ethical principle is upheld when the registered nurse provides medical assistance to victims of an accident?

Beneficence

Which action demonstrates disinfection?

Cleaning the stethoscope with isopropyl alcohol after each use with patients

Which is the best strategy for the nurse to use when communicating with a patient from different culture?

Considering the context of the patient's background

Which assessment findings lead the nurse to suspect that the patient has obstructive sleep apnea?

Daytime sleepiness, snoring, and obesity

Which is the best method to begin teaching the adult patient how to self-administer tube feeding through a new gastrostomy tube?

Demonstration

The nurse is caring for a patient with end-stage chronic obstructive pulmonary disease (COPD). The patient's pulse oximetry reading is 90% on room air. What is the priority action of the nurse?

Determine the patient's normal pulse oximetry values.

Which is the priority action of the nurse immediately after administration of an intramuscular injection?

Engage the safety sheath over the needle.

A new central line care protocol to prevent site infection is instituted after it has been shown to be significantly more effective than previous approaches. Which term best describes this action?

Evidence-based practice

Which protective apparel must the nurse wear to start an intravenous line for the patient?

Gloves only

Which is the best position for a patient who is acutely short of breath?

High-Fowler's

The nurse noted a rise in skin infections on the nursing unit. After a literature review was completed, a new bathing protocol using disposable wash basins and pH balanced skin cleansers was suggested. Which steps of the scientific process were used by the nurse?

Identify the problem.

Which problem is the highest priority for a family who has just moved to the United States and does not speak any English?

Impaired verbal communication

The nurse administers enteric-coated aspirin to the patient. Where will this medication be absorbed into the body?

In the small intestine

Which is the highest priority nursing diagnosis for the patient admitted with pneumonia?

Ineffective airway clearance related to inability to cough up thick secretions

Which action by the nurse best demonstrates independent thinking?

Initiating swallow precautions when the patient shows signs of aspiration

Alteration in consciousness that occurs seemingly without eff ort, typicallywhen we want to momentarily escape reality, is called:

Insomnia

Which ethical principle is upheld when uninsured patients receive the same level of care as patients with private health insurance?

Justice

REM sleep is also known as paradoxical sleep because:

Measures of the brain activity closely resemble waking consciousness,but the person is incapable of moving.

A client presents to the emergency department with lethargy; deep, regular respirations; and a fruity odor to the breath. The client's arterial blood gas (ABG) results are pH of 7.25, Pco2 of 34 mm Hg, Po2 of 86 mm Hg, and HCO3- of 14 mEq/L. The nurse interprets that the client has which acid-base disturbance

Metabolic acidosis

Which ethical principle is upheld when the surgeon refuses to operate on the patient because potential benefit is minimal compared to the pain that the patient will endure?

Nonmaleficence

Which intake and output measurement can the nurse delegate to the nursing assistant?

Oral fluid intake

The nurse is preparing to give a bed bath to an immobilized client with tuberculosis (TB). The nurse would plan to wear which items when performing this care?

Particulate respirator, gown, and gloves

.Which is the first action of the nurse when starting care for the patient at the beginning of the shift?

Perform a focused patient assessment.

The patient lives in an apartment and has difficulty getting on and off of the toilet. Which is the best intervention to protect the patient's safety?

Place a bedside commode over the toilet.

The nurse is caring for a patient who is ordered to remain on bed rest. Which is the appropriate action of the nurse to facilitate emptying of the patient's bladder?

Place the patient in high Fowler's position when using the bedpan

The nurse is having difficulty hearing his patient's apical pulse with his stethoscope. Which action will help the nurse hear the heartbeat more clearly?

Placing the diaphragm firmly against the patient's skin

Which is the highest priority nursing diagnosis for a patient with a spinal cord injury and no pain sensation below the waist?

Potential for injury related to lack of sensation and protective reflexes

A single mother with three children uses the public health department services in the county to immunize her children. Which level of health care did the mother use?

Preventative care

Which action by the nurse helps to meet the cognitive needs of the patient as described by Maslow?

Providing a calm environment when the patient becomes agitated and confused.

Which equipment should the nurse utilize when ambulating a patient with a history of severe COPD?

Pulse oximeter

When in this stage of sleep, brain waves have a fast frequency and lowamplitude and look very similar to beta waves, which occur when you arewide-awake and alert. Which state of sleep is this?

REM sleep

Which technique will provide the most accurate measurement of the patient's core temperature?

Rectally

A patient smokes in the hospital bathroom and starts a fire. Which is the nurse's first response?

Remove the patient to a safe area.

Which task may be delegated to the nursing assistant?

Reposition the patient at least every 2 hours using pillows and foam wedges

Which task may be delegated to the nursing assistant?

Reposition the patient at least every 2 hours using pillows and foam wedges.

Which term is used to describe the nares of a patient after a nasal culture is positive for MRSA?

Reservoir

The nurse is caring for a dyspneic patient with a long history of smoking. The blood gas report shows a pH of 7.33, PaCO2 of 47, PaO2 of 78, and HCO3- of 26. What is the patient's acid-base status?

Respiratory acidosis

The nurse reviews the arterial blood gas results of a client and notes that the results indicate a pH of 7.30, Pco2 of 52 mm Hg, and HCO3- of 22 mEq/L. Which interpretation would the nurse correctly make about these results?

Respiratory acidosis

A client who has fallen from a roof and fractured his ribs has arterial blood gas (ABG) results of: pH 7.48, Paco2 32 mm Hg, Pao2 89 mm Hg, and HCO3- 22 mEq/L. How would the nurse interpret the client's blood gas results?

Respiratory alkalosis

Which patient care need may be delegated to the nursing assistant?

Responding to the patient's bed alarm as the patient attempts to get up

Which agency would be most appropriate for a patient who requires rehabilitation services for right-sided hemiplegia after a stroke?

Restorative care center

Which nursing diagnosis has the highest priority for the patient following a stroke?

Risk for aspiration related to impaired swallowing and absence of gag reflex

Which is the priority nursing diagnosis for a patient with orthostatic hypotension after several days of bed rest?

Risk for falls related to light-headedness upon standing and getting out of bed

Which is the highest priority nursing diagnosis for a patient who is frequently incontinent of stool and urine?

Risk for impaired skin integrity related to exposure to urine and stool

What is the priority nursing diagnosis for a patient with osteoporosis?

Risk for injury (fracture) related to fragile bone tissue

The diabetic patient sees the podiatrist regularly to prevent development of ulcers in the feet. Which term best describes this action of the patient?

Secondary prevention

A nurse is caring for a patient who is visually impaired. Which technique will the nurse use to facilitate communication?

Speak loudly and slowly to facilitate patient understanding

The patient is admitted to the cardiac unit. Everyone admitted to the cardiac unit will have an EKG done unless otherwise ordered. This is an example of which type of order?

Standing

The nurse feels that an assigned duty is outside the scope of nursing practice. Which document is the best source to answer the nurse's concern?

State Nurse Practice Act

Which agency determines which training is required for nurses to start intravenous lines for patients?

State Nurse Practice Acts

Which position should be avoided for a patient who is unconscious?

Supine

The nurse maintains a sterile field when inserting a urinary catheter into the patient's bladder. Which term best describes the infection control practice of the nurse?

Surgical asepsis

Which exercise program should be avoided by a patient with osteoporosis?

Tennis

Which action by the nurse demonstrates the concept of nurse autonomy?

The nurse braids the patient's long hair to prevent tangles.

Which action of the nurse addresses Maslow's need for love and belongingness?

The nurse encourages a widowed patient to join a bereavement support group.

Which action is appropriate for transferring a hemiplegic patient from the bed to the wheelchair?

The nurse secures the gait belt under the patient's arms and uses it to lift the patient to a standing position.

How does the nurse maintain a low center of gravity while transferring the patient from the bed to the chair?

The nurse stands with the knees slightly bent and legs spread apart.

Which action of the nurse demonstrates the use of standard precautions?

The nurse uses gloves when performing oral care for the patient.

Which action of the nurse demonstrates coordination of care for the patient?

The nurse works with the physical therapist to determine how to best transfer the patient from the bed to the chair.

Which chart entry documents patient achievement of cognitive learning

The patient described three symptoms of diabetic ketoacidosis

Which assessment finding indicates that the patient is at high risk for infection?

The patient has a urinary catheter draining clear yellow urine.

The nurse is caring for a patient who is recovering from a cerebrovascular accident. Which assessment finding indicates that the patient's cerebellum was damaged by the stroke?

The patient has poor balance and has an unsteady gait.

Which assessment findings will the nurse communicate to the physician using the SBAR tool?

The patient is having difficulty breathing and the pulse oximetry is 75%.

Which chart entry represents appropriate documentation about the patient's pain assessment?

The patient rated the pain at 2 on a 0-to-10 scale

Which assessment finding is expected for a patient with impaired lung compliance?

The patient struggles to take a deep breath and exhale.

The nurse is caring for a patient with right-sided hemiplegia after a stroke. Which is the appropriate goal for the diagnosis impaired transfer ability related to insufficient muscle strength?

The patient will safely transfer from bed to chair with the assistance of one person

Which patient learning goal is measurable?

The patient will verbalize responsibility for obtaining daily weights each morning.

Which patient's need constitutes the highest priority for the nurse?

The patient with sudden onset of slurred speech and right-sided weakness

Which is an example of normal flora?

The patient's colon contains bacteria to help assist digestion.

A nurse must give feedback to a nursing assistant that did not take vital signs. How will the nurse give feedback?

The patient's vital signs were not taken. What happened?"

Which entry in the patient's chart will justify home nursing care reimbursement from Medicare, Medicaid, and private insurance companies?

The patient's wound was 6 cm × 4 cm and is now 4 cm × 2 cm

Which is the primary purpose of a patient's medical record?

To facilitate professional communication and safe health care

Which action of the nurse will minimize the onset and spread of infection?

Use aseptic technique when providing mouth care to the patient.

Which nursing intervention is appropriate when bathing older adult patients?

Use warm water, mild skin cleanser, and moisturizing lotion.

Which approaches will the nurse use in order to effectively participate in interprofessional collaboration? (Select all that apply.)

Work to maintain a mutual respect. Support a team approach to the maintenance of health Use role-specific knowledge to address health care needs apply relationship-building values and principles of team dynamics

A nurse is caring for a patient who suffers from a sleep pattern disturbance. To promote adequate sleep, which one is NOT the most appropriate nursing interventions? (Select all that apply.)

administer sleep aids every night at the same time

The patient's insurance company refuses to pay for the brand name formulation of a prescribed drug. Which formulation of the drug will the patient receive instead?

generic

the patients daughter requests ro see the patients medical record. what is the nurses appropriate response ?

im sorry but that information is confidential

The registered nurse (RN) reviews the results of the arterial blood gas (ABG) values with the licensed practical nurse (LPN) and tells the LPN that the client is experiencing respiratory acidosis. The LPN would expect to note which on the laboratory result report?

pH 7.25, Pco2 50 mm Hg

Which leadership skills will the nursing student use when caring for patients? (Select all that apply.)

priority setting time management careful delegation team communication

The nurse is caring for an extremely anxious patient. Which assessment findings would be expected as a result of the patient's emotional state?

pulse 125 respiratory rate 32 blood pressure 188/88