Fundamentals final exam study guide PART 1

A nurse is caring for a client who is scheduled to have surgery. In preparing the client for surgery, which of the following actions is considered outside the nurse's responsibilities?

explain the operative procedure, risks, and benefits

A nurse is caring for a client who has cancer and is receiving palliative care. Which of the following statements by the client indicates they understand this type of treatment?

"I am hoping this will limit my discomfort."

A nurse is caring for a client who has a new diagnosis of chronic kidney disease. Which of the following statements should the nurse identify as an indication of anticipatory grieving?

"I just can't believe that my whole life is going to be ruined by dialysis."

A nurse is caring for a client who has been diagnosed with end-stage liver cancer. Which of the following responses is an indication the client is in the denial phase of the grief process?

"The doctor says I only have a few months to live, but I know he is exaggerating to get me to take my medication."

A nurse is caring for an older adult client who has had surgery for an intestinal obstruction and has an NG tube to wall suction. Which of the following interventions should the nurse include in the client's postoperative plan of care? (Select all that apply.)

-Discontinue suction when assessing for peristalsis -irrigate NG tube w/ 0.9% solution -place sequential devices on the bilateral lower extremities -reposition client from side to side every 2 hours -patient should use spirometer every hour while awake

A hospice nurse is reviewing the prescriptions for a client who is receiving palliative care. Which of the following prescriptions should the nurse expect? (Select all that apply.)

-Provide skin care w/ moisture barrier cream -administer artificial tears PRN -perform mouth care every hour -administer oxygen 2L/min nasal cannula

A nurse is planning postoperative care for a client who is scheduled for an ileal conduit (urinary diversion) procedure. The nurse should include which of the following in the client's plan of care? (Select all that apply).

-apply skin barrier around stoma site -educate client that hematuria is expected -watch hourly urine output

A nurse provides a back massage as a palliative care measure to a client who is unconscious, grimacing, and restless. Which of the following findings should the nurse identify as indicating a therapeutic response? (Select all that apply.)

-shoulders droop -facial muscles relax -pulse is within expected range

A nurse is planning care for a client who is postoperative. Which of the following statements about pain management should the nurse consider when implementing client care? (Select all that apply.)

-use of analgesics will eventually lead to addiction -each client's expression of pain may be different and individualized -patient-controlled analgesia offers a constant levels of opioids within therapeutic range -pain level and pain tolerance can be assessed using a scale from 0 to 10

A nurse is working with an assistive personnel (AP) while caring for a surgical client who is 1 day postoperative. Which task should the nurse take responsibility for completing?

Removing the abdominal dressing

A nurse is providing postmortem care for a client. Identify the sequence of steps the nurse should follow. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

1. make sure provider has certified client's death 2. verify the client's organ and tissue donation status -remove medical equipment from client -cleanse the body while adhering to body-fluid precautions -attach identification tags to the body

A nurse is calculating the output of a client at the end of the shift. The nurse notes the following: client voided 400 mL at 1100 and 350 mL at 1430. The closed chest drainage system was previously marked at 155 mL and is now at 175 mL. The NG tube has 575 mL in drainage container, and 25 mL is emptied out of the Jackson-Pratt drainage tube. How many mL should the nurse record in the medical record as the client's output?

1370 mL

A nurse is assessing the respiratory pattern of an older adult client who is receiving end-of-life care. Which of the following assessment findings should the nurse identify as Cheyne-Stokes respirations?

Apnea

A nurse in a dialysis center is caring for a client who has a new diagnosis of end-stage kidney disease. When he arrives for his first dialysis treatment, he tells the nurse, "I decided to come today, but I am not sure if I will need to come back again this week. I am feeling much better since my discharge from the hospital and I think my kidneys are working again." The nurse should identify that this client is demonstrating which of the following Kübler-Ross stages of grieving?

Denial

A nurse is admitting a client who has a partial hearing loss. Which of the following is the priority action by the nurse?

Determine if the client uses hearing aids.

A nurse is caring for a client who has metastatic bone cancer. The client states, "I want to go home to die." The family is concerned about meeting the client's care needs at home. Which of the following actions should the nurse take?

Discuss initiating hospice care with the client and family.

A nurse is developing a plan of care for a client who is postoperative. Which of the following interventions should the nurse include in the plan to prevent pulmonary complications?

Encourage the use of an incentive spirometer

A nurse manager is discussing the differences between normal and maladaptive grief with nursing staff. Which of the following findings should the nurse manager identify as being a unique component of the maladaptive grieving process?

Low self-esteem

A nurse is caring for client who just returned from the PACU with an IV fluid infusion and an NG tube in place following abdominal surgery. Which of the following data is the priority for the nurse to assess?

The surgical dressing (can be indicative of hemorrhage circulation (SABC))

A nurse on a medical unit is caring for a client who suddenly becomes confused and drowsy. Additional data includes pulse 100/min, respiratory rate 24/min, BP 132/76 mm Hg, and temperature 36.8º C (98.2º F). Which of the following actions should the nurse perform?

complete a neuro check since the patient has recently become confused.

A nurse is assessing a client 1 day postoperative following abdominal surgery. Suddenly the client reports a pulling sensation and pain in his surgical incision. Which of the following actions should the nurse take?

cover area with saline soaked sterile dressings.

A nurse is assessing a client who is postoperative and has anemia due to excess blood loss following surgery. Which of the following findings should the nurse expect?

fatigue

A nurse is caring for a client who is postoperative following abdominal surgery. Which of the following findings should indicate to the nurse the client's peristalsis is returning?

passage of flatus

A nurse assesses a hospice client. The assessment reveals BP 74/40, urine output 30 cc over 3 hours, poor skin turgor and skin cool to touch, resp 8 and irregular, and dysphagia. The nurse recognizes these combined assessment findings.

signs of impending death or stroke.

A nurse is assessing a client who is 48 hr postoperative following abdominal surgery. Which of the following findings should the nurse report to the provider?

yellow/green drainage on surgical incision