Fundamentals Practice Questions Exam 2

Which safety tip could the nurse give to parents to help decrease the risk of the leading cause of injury or death in children 1 to 4 years of age?

"Always provide close supervision for young children when they are in or around pools and bathtubs."

A client works in a warehouse and has been having low-back pain. Which statement would indicate the need for more education regarding safe lifting?

"I hold the boxes away from my body so I don't drop them on my feet."

A client asks what trochanter rolls are used for when providing client care. What is the appropriate nursing response?

"To prevent your legs from rotating outward."

A client has undergone foot surgery and will use crutches in the short term. Which teaching point should the nurse provide to the client?

"Your elbows will be slightly bent when you are using your crutches."

The nurse uses gait belts when assisting clients to ambulate. Which client would be a likely candidate for this assistive device?

A client who has leg strength and can cooperate with the movement

The acronym RACE is commonly taught as a means for remembering priorities for action during a fire. The "A" in this acronym stands for which of the following?

Activate the fire alarm and notify the appropriate person.

The nursing student learns in Fundamentals that the primary purpose for using proper body mechanics is for which reason?

Acts to prevent injury to the client and/or nurse

The nurse moves a client's arm from an outstretched position to a position at the side of his body. What is the term used to describe this type of body movement?

Adduction

A client has frequent readmissions for fall-related injuries. Which is the most appropriate intervention by the nurse?

Arrange for a skilled home care assessment

A home care nurse provides health education to parents regarding the care of their toddler. Which precaution should the nurse suggest the parents take to protect the toddler from drowning?

Avoid unattended baths for the toddler.

A nurse is educating parents of preschoolers on appropriate safety measures for this age group. What might be a focus of the education plan?

Childproofing the house

A client is lying on her back with her arms at her side and knees supported with a pillow. What nursing documentation is most appropriate for this client?

Client is in supine position with arms in functional position and pillow support under the knees.

The nurse manager is reviewing the QSEN quality and safety competencies for nurses. Which competencies are included in this initiative? Select all that apply.

Client-centered care Teamwork and collaboration Quality improvement (QI)

A confused client is pulling at the IV line. When considering alternatives to restraints, which nursing intervention would be used first?

Conceal IV tubing with gauze wrap

A health care provider orders extremity restraints for a confused client who is at risk for injury by pulling out her central venous catheter. What is the nurse's most appropriate action when carrying out this order?

Ensure that two fingers can be inserted between the restraint and the client's extremity.

The nurse is transferring the client from the bed to a wheelchair when the client reports dizziness. What is the next step for the nurse?

Firmly grasp the gait belt and gently lower the client into bed.

A client who has been lying prone reports shortness of breath and a sensation of choking. Into which position will the nurse place the client?

Fowler's

When educating families on fire safety in the home, which information is important for the nurse to emphasize?

Have a meeting place outside the home in case of fire.

A nurse receives an order to apply graduated compression stockings for a client at risk for venous thromboembolism. How should the nurse apply the stockings?

If the client was sitting up, have him or her lie down and elevate feet for 15 minutes before applying stockings.

Which statement should the nurse include in the education plan regarding safety issues for a group of adult clients?

In most age groups, motor vehicle accidents are major causes of death.

The unlicensed assistive personnel (UAP) tells the nurse that a client is very confused and trying to get out of bed without assistance. What is the appropriate action by the nurse?

Initiate use of a bed alarm.

The nurse is caring for a client that is disoriented. The nurse places the client in soft wrist restraints to discourage pulling at a nasogastric tube. Which nursing action(s) is appropriate? Select all that apply.

Obtain order from a licensed provider within minutes of restraint application. Offer regular, frequent opportunities for toileting. Check circulation and skin condition every 2 hours.

The nurse is teaching the caregiver of a 3-year-old about safety. Which teaching will the nurse include?

Place all household cleaners out of reach.

The nurse directs the unlicensed assistive personnel (UAP) to help a partially blind older adult client with meals. Which information is appropriate for the nurse to provide the UAP to facilitate the client's comfort and safety during mealtime? Select all that apply.

Place client in upright position at a 45- to 90-degree angle in the bed or chair Provide verbal cues regarding location of food on plate Cut food into small pieces Ensure that the temperature of food is safe

A nurse responds to the call bell and finds another nurse evacuating the client from the room, which has caught fire. Which action should the nurse take?

Pull the fire alarm lever.

The nurse is assisting a client from the bed into a wheelchair. What is a recommended guideline for this procedure?

Raise the head of the bed to a sitting position.

The nurse is providing discharge teaching to the family of an older adult client. Which teaching will the nurse include to decrease the risk for electric shock?

Refrain from using extension cords.

The nurse on a medical-surgical unit notices smoke from a client's room. Upon entering, the nurse notes that the curtain in the room is on fire. What should be the nurse's first action?

Remove the client from the room.

A nurse is preparing discharge education for a client with a newborn baby. What is the highest priority item that must be included in the education plan?

Restrain the baby in a car seat.

The nurse has completed a comprehensive assessment of a client who has been admitted to the hospital experiencing acute withdrawal from alcohol. What nursing diagnosis would provide the clearest justification for the use of physical restraints during this client's care?

Risk for Injury Related to Agitation

The nurse is caring for a client with hemorrhoids. To facilitate a rectal examination, into which position will the nurse place the client?

Sims'

The nurse is caring for a client with rectal bleeding. The nurse will place the client into which position to facilitate rectal examination?

Sims'

The nurse is caring for an 80-year-old client who was admitted to the hospital in a confused and dehydrated state. After the client got out of bed and fell, restraints were applied. She began to fight and was rapidly becoming exhausted. She has black-and-blue marks on her wrists from the restraints. What would be the most appropriate nursing intervention for this client?

Take the restraints off, stay with her, and talk gently to her.

The client is ambulating in the room and walks around a bedside table. What is the best explanation for why the client does not bump into the table?

The client is aware of spatial relationships to avoid the table.

The nurse is considering the use of a power stand-assist machine with a client who has difficulty getting out of bed. The nurse will choose a different assistive device if which assessments are present? Select all that apply.

The client is oriented to self, but not time or place. The client makes no attempt to help with transfers.

A nurse is completing an intake assessment. The nurse notes that an older adult male client appears to have bruises in varying stages of healing. Which action by the nurse indicates an understanding of her responsibilities?

The nurse should question the client about the source of the bruises.

A team of inner city school nurses attends a community conference on child safety during the summer months. What would be the priority health outcome that these nurses would expect to achieve in summer school?

The students will demonstrate proper use of safety equipment while playing sports.

In an assessment for proper body alignment of a standing client, which finding is normal?

The weight of the body is distributed on the soles and heels.

The nurse teaches proper body mechanics for a group of unlicensed assistive personnel (UAP). Which statement by a class participant indicates the need for additional education?

When I lift and carry a heavy box of supplies I will keep it at arm's length from my body.

Which type of mobility aid would be most appropriate for a client who has poor balance?

a cane with four prongs on the end (quad cane)

A nurse is caring for an 18-month-old client after a tracheostomy. The client is recovering well and noted a desire to be more active. The nurse selects a toy from the playroom for the client to play with. Which toy is most developmentally appropriate?

a rocking horse

The nurse is caring for a client who has been repetitively pulling at IV lines and the urinary catheter. After other methods of diverting the client's behaviors fail, the health care provider orders chemical restraints. Which treatment does the nurse anticipate?

administration of an antipsychotic agent to alter the client's behavior

A nurse is providing care to a client confined to bed. To promote independence while the client is moving in bed and provide the client assistance in moving up in bed, which device would be appropriate?

bed trapeze

A 45-year-old man is interested in starting an exercise program. The nurse informs him that exercise does not:

decrease appetite.

What is a benefit of regular exercise over time?

decreased heart rate

A nurse applies padded boots to maintain the foot in dorsiflexion to a client who is comatose. The nurse is protecting the client from:

foot drop.

Which topic should a public health nurse emphasize when educating older adults on reducing their risk of poisoning?

keeping medications in clearly labeled containers

The nurse directs the unlicensed assistive personnel (UAP) to assist an inactive client with positioning. Which action by the UAP would cause the nurse to intervene?

lowering the height of the bed prior to moving the client

The nurse is delegating inactive client positioning to a UAP. What directions will the nurse include?

placing the client in good alignment with joints slightly flexed

A nurse is preparing to turn a client who is unable to mobilize independently. Which action best ensures the safety of both the client and the nurse?

positioning a friction-reducing sheet under the client to facilitate movement

The nurse is assessing a client who is bedridden. For which condition would the nurse consider this client to be at risk?

predisposition to renal calculi

A nurse is conducting a home assessment of a 90-year-old client with a history of several minor strokes that have left the client with a hemiplegic gait. The nurse is particularly concerned about falls. Which activities would help to prevent falls for this client? Select all that apply.

removing clutter from the floor placing nightlights in the bathroom and hallways moving the bedroom to the ground floor

The nurse has been educating the client about how to use a walker safely. The nurse knows that the education has been effective when the client:

steps into the walker when walking.

The pediatric nurse is caring for a 3-week-old infant. In which position will the nurse place the infant to sleep?

supine

The pediatric nurse is caring for a newborn infant. In which position will the nurse place the infant to sleep?

supine

The nurse is assessing the developmental level of children in a pediatric clinic. The nurse would be most concerned about which client?

the 24-month-old child who is unable to walk unassisted

A home care nurse visits a client with Parkinson's disease. The nurse observes that the client has rhythmic, repetitive movements of the hands. The home care nurse documents this as:

tremor