Fundamentals Practice B

A nurse is caring for a client who has tuberculosis. Which of the following actions should the nurse take?

-Place the client in a room with negative-pressure airflow. -Wear gloves when assisting the client with oral care. -Use antimicrobial sanitizer for hand hygiene.

A nurse is preparing to obtain a lower extremity blood pressure from a client and no longer palpated the popliteal pulse after 92 mm Hg. Which of the following images displays the measurement in mm Hg to which the nurse should inflate the cuff when obtaining the blood pressure?

120 mm Hg (Inflate the cuff 30 mm Hg beyond the point at which the nurse was last able to palpate the pulse.)

A nurse is caring for a group of clients on a medical surgical unit. Which of the following situations does the nurse demonstrate the ethical principle of veracity?

A client unaware of her recent cancer diagnosis asks the nurse if she has cancer, and the nurse responds affirmatively.

A community health nurse is checking blood pressures for a group of clients at a community health screening. Which of the following clients is at an increased risk for hypertension?

A client who smokes one pack of cigarettes each day

A nurse manager is overseeing the care activities on a unit. For which of the following situations should the nurse manager intervene due to a violation of HIPAA guidelines

A nurse asks a nurse from another unit to assist with documentation for a client

A nurse is preparing to delegate client care tasks to an assistive personnel. Which of the following tasks should the nurse delegate?

Ambulatory a client who is postoperative

A nurse has just inserted an NG tube for a client. Which of the following findings should the nurse expect to confirm the correct tube placement?

An x-ray shows the end of the tube above the pylorus

A nurse is planning care for a client who has vision loss. Which of the following interventions should the nurse include in the plan of care to assist the client with feeding?

Arrange food in a consistent pattern on the clients pkate

A nurse is preparing to transfer a client who can bear weight in one leg from the bed to the chair. After securing a safe environment, which of the following actions should the nurse take next?

Assess the client for orthostatic hypotension

A nurse is administering IV fluids to a client. When monitoring for adverse effects, which of the following assessments should the nurse identify as the priority?

Auscultate lung sounds

A nurse is caring for a client who has a prescription for wound irrigation. Which of the following actions should the nurse take?

Cleanse the wound from the center outward (To prevent introduction of micro-organisms from the outer skin surface)

A nurse is assessing a client who received an IV fluid boils for dehydration. Which of the following findings should the nurse identify as an indication of fluid volume excess?

Distended neck veins (Fluid volume excess includes distended neck veins, edema, tachycardia, crackles in the lungs, dyspnea (difficulty breathing), a bounding pulse, and an increase in BP)

A nurse is admitting a client who has rubella. Which of the following types of transmission based precautions should the nurse initiate?

Droplet (Includes influenza, rubella, meningococcal pneumonia, and streptococcal pharyngitis)

A nurse is assessing an adult who has been immobile for the past 3 weeks. For which of the following findings should the nurse intervene?

Erythema (red rash) on pressure points

A nurse is planning to administer multiple medications to a client who has an enteral tube feeding. Which of the following actions should the nurse plan to take?

Flush the tube with 15 mL of sterile water (15mL-30mL before and between. 30-60mL after)

A nurse is preparing to administer 0.5 mL of oral single dose liquid medication to a client. Which of the following actions should the nurse take?

Gently shake the container of medication prior to administration.

A nurse is preforming a Romberg test during the physical assessment of a client. Which of the following techniques should the nurse use?

Have the client stand with their arms at their sides and their feet together

A nurse is caring for a client who had limited mobility in his lower extremities. Which of the following actions should the nurse take to prevent skin breakdown?

Have the client use a trapeze bar when changing positions

A nurse is preforming a peripheral vascular assessment for a client, when placing the bell of the stethoscope on the clients neck, the nurse hears the following sound. This sound indicates which of the following?

Narrowed arterial lumen (blowing sounds resulting from blood flowing through occluded or narrowed arteries are known as a bruit)

A nurse is planning teaching to a group of adolescents who each recently had surgical placement of an ostomy. Which of the following methods should the nurse use as a psychomotor approach to the learning?

Practice sessions

A nurse is caring for a client who is receiving fluid through a peripheral IV catheter. Which of the following findings at the IV site should the nurse identify as indicating filtration?

Skin blanching (Also edema and coolness indicate infiltration)

A nurse is caring for a client who has an NG tube and is receiving intermittent feedings through an open system. Which of the following actions should the nurse take first?

Tell the client to keep the head of the bed elevated at least 30 degrees.

A nurse is caring for a client who reports pain. When documenting the QUALITY of the clients pain on an initial assessment, the nurse should record which of the following client statements?

The pain is like a dull ache in my stomach

A nurse is caring for a client who has terminal liver cancer. Which of the following statements should the nurse identify as an indication that the t is experiencing spiritual distress?

What could I have done to deserve this illness

A nurse is caring for a client who is refusing a blood transfusion for religious reasons. The clients partner wants the client to have the blood transfusion. Which of the following actions should the nurse take?

Withhold the blood transfusion. (The principle of autonomy ensures that a client who is competent has the right to refuse treatment)

A nurse is admitting a client who has been having frequent tonic-clonic seizures. Which of the following actions should the nurse add to the clients plan of care?

wrap blankets around all four side rails

A home health nurse is completing an admission assessment of an older adult client who has their caregiver present. Which of the following findings should the nurse identify as a potential indication of elder abuse?

The caregiver insists on remaining in the room

A nurse is discussing the use of herbal supplements for health promotion to a client. Which of the following client statements indicates an understanding of herbal supplement use?

I can take echinacea to improve my immune system (Echinacea is taken to promote immunity and reduce the risk of infection)

A nurse is caring for a client who is receiving 24 hour urine collection. Which of the following statements by the client indicates an understanding of the teaching?

I flushed what I urinated at 7:00 am and have saved all urine since

A nurse is reviewing protocol in preparation for suctioning secretions from a client who has a new tracheostomy. Which of the following actions should the nurse plan to take?

Select a suction catheter that is half the size of the lumen. (prevent hypoxemia and trauma to the mucosa)

A charge nurse is observing a newly licensed nurse prepare a sterile field for a dressing change. Which of the following actions by the newly licensed nurse requires intervention by the charge nurse?

The newly licensed nurse placed the cap of the bottle of sterile saline solution on the sterile field

A nurse is teaching an older adult client who is at risk for osteoporosis about beginning a program of regular physical activity. Which of the following types of activity should the nurse recommend?

Walking briskly

A nurse is planning an educational program for a group of older adults at a senior living center. Which of the following recommendations should the nurse include?

You should receive a pneumococcal immunization every 10 years

A charge nurse is discussing the responsibility of nurses caring for clients who have C. difficile. Which of the following information should the nurse include in the teaching?

Have family members wear a gown and gloves when visiting

A nurse is caring for a client who is receiving pain medication through a patient controlled analgesia pump. Which of the following actions should the nurse take?

Instruct the family to refrain from pushing the button for the client while she is asleep

A middle adult client tells the nurse, "I feel so useless now that my children do not need me anymore." Which of the following responses should the nurse make?

"People in middle adulthood often find satisfaction in nurturing and guiding young people." (Erikson- generativity vs self-absorption and stagnation)

A nurse is caring for a client who has decreased mobility. Which of the following actions should the nurse take to decrease the clients risk of developing plantar flexion contractures?

Apply an ankle foot orthotic device to the clients feet (Maintains dorsiflexion)

size of the lumen. A nurse in an acute care facility is preparing a discharge summary for a client who is transferring to a long term care facility. Which of the following documentation should the nurse include?

Current medications

A nurse is completing an admission assessment for a client who reports vomiting and diarrhea for the past 3 days. Which of the following findings should the nurse expect?

Rapid heart rate (Tachycardia indicates fluid volume deficit, which is an expected finding for a client who has had vomiting and diarrhea for 3 days.)

A nurse in a clinic is caring for a middle adult client who states, "the doctor says that, since I am at an average risk for colon cancer, I should have a routine screening. What does that involve?" Which of the following responses should the nurse make?

You should have a fecal occult blood test every year (Average risk begins at age 50 and to have done annually)

A nurse is giving change-of-shift report about a client they admitted earlier that day who has pneumonia. Which of the following pieces of information is the priority for the nurse to provide?

Breath sounds

A nurse enters a clients room and finds her on the floor. The clients roommate reports that the client was trying to get out of bed and fell over the side rail onto the floor. Which of the following statements should the nurse document about this incident?

Client found lying on floor (Should be objective)

A nurse is reviewing practice guidelines with a group of newly licensed nurses. Which of the following interventions should the nurse include that is within the scope of RN practice?

Initiate an enteral feeding through a gastrostomy tube

A nurse is caring for a client who reports difficulty falling asleep. Which of the following recommendations should the nurse make?

Maintain a consistent time to wake up each day

A nurse is teaching a client whose left leg is in a cast about using crutches. Which of the following statements should the nurse identify as an indication that the client understands the teaching?

when descending stairs, I will first shift my weight to my right leg.

A nurse is caring for a client who has recently started using a behind the ear hearing aid. Which of the following statements should the nurse identify as an indication that the client understands the use of this assistive device?

"I will be sure to remove my hearing aid before taking a shower"

A nurse is caring for a client who has a terminal diagnosis and whose health is declining. The client requests information about advance directives. Which of the following responses should the nurse make?

"We can talk about advance directives, and I can also give you some brochures about them."

A nurse is calculating a client's fluid intake over the past 8 hr. Which of the following should the nurse plan to document on the client's intake and output record as 120 mL of fluid?

8 oz of ice chips (document half volume of ice chips. 1 oz = 30 mL)

A nurse is teaching a group of staff nurses about the use of essential oils for aromatherapy. The nurse should include in the teaching that this therapy might be contraindicated for which of the following clients?

A client who has asthma

A nurse is caring for a client who has an in dwelling urinary catheter. Which of the following findings indicates that the catheter requires irrigation?

Bladder scan shows 525 mL of urine

A nurse is providing discharge teaching for a client who has a new prescription for a home oxygen concentrator. Which of the following instructions should the nurse provide to the client and his family?

Check the cord routinely for grays or tearing Consider purchasing a generator for power backup Observe for signs of hypoxia

A nurse on a medical unit is preparing to discharge a client to home. Which of the following actions should the nurse take as part of the medication reconciliation process?

Compare prescriptions with medications the client received during hospitalization.

A nurse in a surgical suite notes documentation on a client's medical record he has a latex allergy. In preparation for the client's procedure, which of the following precautions should the nurse take?

Wrap monitoring cords with stockinette and tape them in place

A client who is nonambulatory notifies the nurse that his trash can is on fire. After the nurse confirms the fire, which of the following actions should the nurse take next?

evacuate the client