Fundamentals Practice Quiz 2

A nurse is caring for a client who is postoperative and who has an indwelling urinary catheter to gravity drainage. The nurse notes no urine output in the past 2 hours. Which action should the nurse take first? Check to determine if the catheter tubing is kinked Palpate the bladder Obtain a prescription to irrigate the catheter with 0.9% sodium chloride. Encourage the client to drink more fluids.

Check to determine if the catheter tubing is kinked

A nurse is assisting a client who is eating at mealtime when the client grabs her neck with both hands and appears frightened. Which action should nurse take first? Place oxygen mask on client Check client's pulse Determine whether the client is able to breathe Wrap arms around the client from behind

Determine whether the client is able to breathe

Where should the nurse administer an intramuscular injection an adult client who is overweight? Lower, medial quadrant of buttock near the coccyx Side hip between iliac crest and anterior iliac spine Tissue of posterior upper arm Lower, inner thigh 4 finger widths above the patella

Side hip between the iliac crest and anterior iliac spine

A nurse is performing suctioning for a client who has a tracheostomy. Which of the following actions should the nurse take? Pull suction catheter back 1 cm if client starts coughing Allow 30 seconds between suctioning passes Hyperventilate client with 50% oxygen for 30 seconds Perform a maximum of 4 passes with suction catheter

Pull suction catheter back 1 cm if client starts coughing

A nurse is caring for a client with history of dysrythmias. Upon entering the room, she discovers the client is unresponsive to verbal or painful stimuli, has no respirations, and is pulseless. Which action should nurse take first? Start chest compressions Provide breaths with manual resuscitation bag Administer oxygen Establish an airway

Start chest compressions

A nurse is assessing a client who has an onset of severe back pain of unknown origin. Which of the following questions should the nurse ask to encourage discussion with the client? Does the medication you're taking relieve the pain? Can you point to where the pain is the worst? What do you think caused the onset of your pain? Changing positions makes your pain worse, right?

What do you think caused the onset of of your pain?

A nurse is planning care for a group of patients who are receiving oxygen therapy. Which of the following clients should the nurse plan to see first? A client who has heart failure and is receiving 100% O2 via partial rebreather A client who has emphysema and is receiving at 3L/min via a transtracheal oxygen cannula A client with old tracheostomy, receiving 40% humidified oxygen via trach collar A client with COPD that is receiving oxygen at 2L/min via nasal cannula

A client who has heart failure and is receiving 100% O2 via partial rebreather

A nurse is caring for a client who had a mastectomy and has a self-suction drainage system in place. Which action should the nurse take to ensure proper operation of the device? Irrigate the tubing with sterile normal water once each shift Cleanse the opening with soap and water after emptying Maintain the tubing above the level of the surgical incision Collapse the device of air after emptying

Collapse the device of air after emptying

A nurse is caring for a client who has an NG tube for intermittent enteral feedings. Which action should the nurse take? Auscultate for bowel sounds after each feeding Ensure the formula is cold before administering Elevate client's head of bed 45 degrees before feeding Flush the tubing with 15 mL of water after the enteral feeding

Elevate client's head of bed 45 degrees before feeding

A nurse is preparing to insert an NG tube for a client with a bowel obstruction. Which of the following actions should the nurse take first? Provide client with glass of water Assist client to sitting position Explain the procedure to the client Measure the length of tubing to be inserted

Explain the procedure to the client

A nurse is caring for a client who has a hearing impairment. Which method should the nurse use when speaking with the client? Speak directly into the client's impaired ear. Exaggerate lip movements Speak loudly Face the client when speaking

Face the client when speaking

A nurse is preparing to anchor with tape the catheter tube for a male client who has a newly inserted Foley catheter. At which of the following locations should the nurse tape the catheter? Lateral thigh Lower abdomen Mid-abdominal region Medial thigh

Lower abdomen

A nurse is changing the dressings for a client who has two Penrose drains near an abdominal incision. Which of the following adhering devices is the best choice for skin irritation? Abdominal binder Montgomery straps Hypoallergenic tape Plastic tape

Montgomery straps

A nurse is preparing to remove an NG tube for a client who had a partial colectomy. Which of the following actions should the nurse take? Maintain suction while removing the NG tube Instill 100 mL of air into the NG tube before removal Pinch the NG tube when removing the tube Instruct the client to breathe in and out during the removal of the NG tube.

Pinch the NG tube while removing the tube

A nurse is preparing to assist in ambulation of an older adult client who was on bed rest for 3 days. Which action should nurse take to decrease the risk of a fall? Use a gait belt during ambulation Ensure the client is wearing socks before ambulating Instruct the client to sit at edge of bed for 15 seconds before ambulating Walk 2 feet behind the client during ambulation

Use a gait belt during ambulation

A nurse is applying antiembolitic stockings for a client who has a history of DVT. Which action should nurse take when applying the stockings? Roll the stocking partially down if too long Remove the stocking once per day Bunch and pull the stocking halfway up the calf Turn the stocking inside out up to heel before applying

Turn the stocking inside out up to heel before applying

A nurse is providing teaching to a client who has a new colostomy about proper care. Which of the following is information the nurse should include? Change the colostomy bag following breakfast. Cleanse the skin around the stoma with warm water. Change the pouch every day. Place an aspirin in the ostomy pouch to decrease odor.

Cleanse the skin around the stoma with warm water.

A nurse is changing the dressings for a client recovering from an appendectomy following the ruptured appendix. The client's surgical wound is healing by secondary intention. Which of the following observations should the nurse report to the provider? Tenderness when touched Pink, shiny tissue with a granular appearance Serosanguineous drainage A halo of erythema on the surrounding skin

A halo of erythema on the surrounding skin

A nurse is collecting a urine specimen for culture and sensitivity in a patient with UTI. Patient has urinary catheter in place. Which action should the nurse take? Withdraw the specimen from the drainage bag. Cleanse collection port with soap and water. Place the specimen in a clean specimen cup. Clamp the tubing below the collection port.

Clamp the tubing below the collection port.

A nurse is planning care for a client who has a wound infection following abdominal surgery. To promote healing and fight infection, which of the following vitamins and minerals should the nurse plan to increase in the client's diet? Vitamin C and zinc Vitamin D Vitamin K and iron Calcium

Vitamin C and zinc

A nurse is planning care for an adult client who has fluid volume excess. Which of the following interventions should the nurse plan to include to monitor the client's weight? Calibrate scales weekly Use a different scale each time Weigh the client on arising Weigh the client without clothing

Weigh the client on arising

A nurse is caring for a client with major fecal incontinence and reports irritation in the perineal area. Which of the following action should the nurse take first? Apply fecal collection system Apply barrier cream Cleanse and dry the area Check the client's perineum

Check the client's perineum

A nurse is teaching a client who is recovering from gallbladder surgery how to use an incentive spirometer. Which of the following information should the nurse include in the teaching? Exhale slowly to reach goal volume. Hold breath for 5 seconds after goal volume is reached Continue to deep breathe after each cycle. Limit repeat pattern of breathing to 5 breaths.

Hold breath for 5 seconds after goal volume is reached

A nurse is changing bed linens for a client who is on bed rest. Which action should the nurse take? Place the soiled linens on the chair while making the bed. Hold the linens away the body and clothing Place the linens on the floor until able to place it in a linen bag. Shake the clean linens to unfold.

Hold the linens away from the body and clothing

A nurse is administering a cleansing enema to a client who is scheduled for a diagnostic procedure. Which of the following actions should the nurse take? Lubricate up to 3.2 cm on the tip of rectal tube Position client on his right side Insert the tip of the tubing 8 cm Hold the enema container 61 cm above the rectum

Insert the tip of tubing 8 cm

A nurse is performing a straight urinary catheterization for a female client with urinary retention. Which of the following actions indicates the nurse is maintaining sterile technique? Applies sterile gloves to open catheter package Wipes labia minora in anteroposterior direction Spreads the labia with the dominant hand Uses one cotton ball to wipe the right and left labia majora

Wipes labia minora in anteroposterior direction

A nurse is caring for a toddler when the mother calls to the nurse "Help! My baby is choking on his food!. Which of the following findings indicate the baby has an airway obstruction? Flushing of the skin Inability of the toddler to cry or speak Presence of nausea and mild emesis Capillary refill time of 1.5 seconds

Inability of the toddler to cry or speak

A nurse is planning to administer pain medication to a client who has pain post-abdominal surgery. Which of the following action should nurse take first? Use a pain scale to determine pain level. Discuss the adverse effects of pain medication with the client Obtain the client's vital signs Check the client's allergies

Use a pain scale to determine pain level

A nurse is replacing the surgical dressings on a client who had abdominal surgery. Which of the following actions should the nurse take? Don clean gloves to remove the old dressing. Loosen the dressing by pulling the tape away from the wound. Remove the entire old dressing at once. Open sterile supplies after sterile gloves.

Don clean gloves to remove the old dressing

How should a nurse administer eye drops in a post-surgical patient? Drop the eye medication in the outer third of the lower conjunctival sac. Apply gentle pressure in the outer opening of the eye for 2 minutes. Hold the eye dropper 0.5 cm/ 0.2 in from the cornea. Instruct the client to close eyes tightly after administration

Drop the eye medication in the outer third of the lower conjunctival sac.

A nurse is performing eye irrigation for a client who has been exposed to smoke and ash. Which action should the nurse take? Hold the irrigator 1.25 cm (0.5 in) above the eye. Direct the irrigation solution upward toward the upper eyelid. Exert pressure on the bony prominences when holding the eyelids open. Direct the irrigation from the outer canthus to the inner canthus of the eye.

Exert pressure on the bony prominences when holding the eyelids open.

A nurse is planning care for a client who has a prescription for a collection of sputum specimen for culture and sensitivity. Which of the following actions should the nurse take when obtaining the specimen? Collect the specimen upon arising in the morning Force fluids during the day and collect the specimen in the evening Collect the specimen after antibiotics have been started. Collect 2 mL of sputum before sending the specimen to the lab.

Collect the specimen upon arising in the morning

Which of the following findings should the nurse identify as an infiltration of an IV infusion site? Redness at IV catheter entry site A palpable cord is felt along the vein used for infusion Taut skin around IV catheter site that is cool to the touch Bleeding at the IV insertion site

Taut skin around IV catheter site that is cool to the touch

A nurse is providing teaching to a group of unit nurses about wound healing by secondary intention? Which of the following info should she include? The wound edges are well-approximated The wound is closed at a later date. A skin graft is placed over the wound bed. Granulation tissue fills the wound during healing.

Granulation tissue fills the wound during healing.

A nurse is caring for a client who is post-op following a vaginal hysterectomy. She asks for something to drink. Her post-op diet prescription reads- clear liquids, advance diet as tolerated. Which response should nurse make? Lunch trays should be here within the hour. I am going to listen to your abdomen. I'll get you some water to drink. I would wait a bit, or you could feel sick.

I am going to listen to your abdomen

A nurse is caring for an older adult client who has dysphagia. Which action should the nurse take when assisting the client at mealtime? Encourage the client to drink fluids before swallowing food. Offer the client tart or sour foods first. Tilt the client's head backward when swallowing Turn on the television

Offer the client tart or sour foods first

A nurse is planning to collect a stool specimen for ova and parasites from a client who has diarrhea. Which of the following actions should the nurse take when collecting the specimen? Instruct client to defecate into toilet bowel. Transfer specimen to sterile container. Refrigerate collected specimen. Place the stool specimen collection container into biohazard bag.

Place the stool specimen collection container into biohazard bag.

The nurse observes yellow, thick drainage on the dressing for a client who is 3 days post-operative from cholecystectomy. How should she document this finding? Sanguineous exudate Serous exudate Serosanguineous exudate Purulent exudate

Purulent exudate

A nurse is helping a client change his hospital gown. The client has an IV infusion on an infusion pump. Which action should the nurse take first? Remove sleeve of gown from arm without IV line. Slow the infusion using the roller clamp Disconnect the IV line from the pump. Bring the IV solution and tubing from the outside to the end side of the sleeve of the gown.

Remove sleeve of gown from arm without IV line.

A nurse is planning care for a client who is confused and requires a prescription for wrist restraints. Which of the following interventions should the nurse include in the care plan? Renew prescription for restraints within 24 hours Secure restraints with buckle side next to client's skin Ensure 4 fingers can be inserted under secured restraint Remove the restraint every 3 hr.

Renew prescription or restraints within 24 hours