Fundamentals Proctor Practice

A nurse is caring for a client who has a stage II pressure ulcer. Which of the following wound dressings should the nurse apply to the ulcer? A.) Hydrocolloid B.) Collagen C.) Calcium alginate D.) Proteolytic enzyme

A.) Hydrocolloid This type of dressing is applied to absorb exudate and to produce a moist environment that will facilitate healing while preventing maceration of surrounding skin.

A nurse is assessing a client's respiratory system. Which of the following breath sounds should the nurse expect to hear over the periphery of the major lung fields? A.) Vesicular B.) Bronchial C.) Rhonchi D.) Bronchovesicular

A.) Vesicular The nurse will hear vesicular sounds over the periphery of the major lung fields. These sounds are soft and low-pitched

A charge nurse is observing a newly licensed nurse perform tracheostomy care for a client. Which of the following actions by the newly licensed nurse requires intervention? A.) Obtaining hydrogen peroxide for tracheostomy care B.) Obtaining cotton balls for tracheostomy care C.) Obtaining sterile gloves for tracheostomy care D.) Obtaining a sterile brush for tracheostomy care

B.) Obtaining cotton balls for tracheostomy care Cotton ball particles can be aspirated into the tracheostomy opening, possibly causing a tracheal abscess.

A community health nurse is preparing a campaign about seasonal influenza. Which of the following plans should the nurse include as a form of secondary prevention? A.) Holding a community clinic to administer influenza immunizations B.) Screening groups of older adults in nursing care facilities for early influenza manifestations C.) Educating parents of young children about the dangers of influenza D.) Finding rehabilitation programs for older adults who have complications related to influenza

B.) Screening groups of older adults in nursing care facilities for early influenza manifestations. Secondary prevention is focused on preventing complications of an illness or providing care to prevent an illness from becoming severe.

A nurse is reviewing the laboratory data of a client who has a fever and watery diarrhea. Which of the following results should the nurse report to the provider? A.) Calcium 9.5 mg/dL B.) Sodium 150 mEq/L C.) Potassium 4 mEq/L D.) Magnesium 1.5 mEq/L

B.) Sodium 150 mEq/L A sodium level of 150 mEq/L is greater than the expected range of 135-145. The client is at risk for dehydration due to diarrhea. Hypernatremia is a manifestation of dehydration.

A nurse is teaching a middle-aged female client about disease prevention and health maintenance. Which of the following diagnostic tests should the nurse recommend as part of this client's routine health screening? A.) Annual Papanicolaou (Pap) Testing B.) Mammogram every 2 years C.) Eye examination every 2 years D.) Annual colonoscopy

C.) Eye examination every 2 years This is essential for monitoring vision and checking for glaucoma. Client should have annual eye examinations from the age of 65 onward.

A nurse is caring for a client with dehydration who has developed hypovolemic shock. Which of the following laboratory values should the nurse expect for this client? A.) BUN 18 mg/dL B.) Capillary refill 1.5 sec C.) Hct 55% D.) Urine specific gravity 1.001

C.) Hct 55% An elevated hematocrit indicates hypovolemia. Normal range for men is 45%-52% Normal rage for women is 37%-48%

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

D.) Granulation tissue fills the wound during healing. A beefy, red tissue called granulation tissue fills the wound during healing. The wound is left open to drain and heal by secondary intention, which should occur within 5-21 days.

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

D.) Turn the stocking inside out up to the heel before applying Makes application of the stocking easier and causes fewer constrictive wrinkles