Fundamentals Review

A nurse is demonstrating postop deep breathing and coughing exercises to a client who is scheduled for emergency surgery for appendicitis. Which of the following statements indicates a lack of readiness to learn by the client? A. The client asks the nurse to repeat the instructions before attempting the exercises B. The client reports severe pain C. The client asks the nurse how often deep breathing should be done after surgery D. The client tells the nurse that this exercise will probably be painful after surgery

B. The client reports sever pain

A nurse delegated the task of emptying an indwelling urinary catheter drainage bag to an aide. The nurse later observes the AP emptying the bag without wearing gloves. Which of the following actions should the nurse take? A. notify the charge nurse about the incident B. Insist that the aide attend an inservice training about standard precautions C. Talk with the aide about the technique used D. Observe the aide a second time andintervene if the technique remains the same

C. talk about the aide about the technique used

A nurse is caring for a client who is unstable and has vital signs measured every 15 minutes by an electronic blood pressure machine. The nurse notices the machine begins to measure the blood pressure at varied intervals, and the readings are inconsistent. Which of the following actions should the nurse take? A. Turn on the machine every 15 min to measure the clients blood pressure B. Record only the blood pressure readings needed for 15 min intervals C. Obtain manual and automatic readings and compare them D. Disconnect the machine and measure the blood pressure manually every 15 minutes

D. Disconnect the machine and measure the blood pressure manually every 15 minutes

A hospice nurse is reviewing religious preactices of a group of clients with a newly licensed nurse. Which of the following statements by thee newly licensed nurse indicates an understanding of the teaching?

People who practice Judaism stay with the body of the deceased unto burial

A nurse is planning to perform passive range of motion exercises for a client. Which of the following actions should the nurse take? A. Repeat each joint motion 5 times during each session B. Move the joint. to the point of considerable resistance C. Sit approximately 2 ft from the side of the bed closest to the joint being exercised D. exercise the smaller joints first

a. Repeat each joint motion 5 times during each session.

A nurse is preparing to assist an older adult client with ambulation following bed rest for 3 days. Which of the following actions should the nurse take to increase the risk of a fall? A. Use a gait belt during ambulation b. Ensure the client is wearing socks before ambulating c. Instruct the client to sit on the edge of the bed for 15 sec before ambulating D. Walk 2ft behind the client during ambulation

A. Use gait belt during ambulation

A nurse is performing a breast examination for a female client. Which of the following techniques should the nurse use first? A. Inspect both breasts simultaneously B. Squeeze the nipples C. Palpate the breast and tail of Spence D. Palpate the axillary lymph nodes

A. Inspect both breasts simultaneously.

A nurse is caring for a group of clients. Which of the following tasks should the nurse assignng to the aide? A. Provide oral care to a client who cannot take oral fluids B. Check a clients IV insertion site for manifestations of infiltration C. Assess a clients ability to ambulate D. Demonstrate the use of a glucometer to a patient

A. Provide oral care to a client who cannot take oral fluids

A nurse is caring for a client who is unconscious. Which of the following actions should the nurse take when providing oral care for the client? A. Test for the presence of the clients gag reflex B. Place the client in the supine position. C. Use a firm toothbrush for tooth and gum care D. Use a 2 gauze wrapped fingers to hold the mouth open

A. Test for the presence of the clients gag reflex

A nurse is performing a physical assessment of a client. The nurse should recognize that which of the following findings places the client at risk of impaired skin integrity? A. 3+ achilles reflex B. Faint pedal pulses C. Feet warm to the touch bilaterally D. Capillary refill of <2 sec

B. Faint pedal pulses

A nurse is assessing a client who is experiencing an obstruction of the flow of the vitreous humor in the eye. The manifestation is consistent with which of the following eye disorders? A. Retinopathy B. Glaucoma C. Cataracts D. Macular degeneration

B. Glaucoma

A nurse is caring for a client with dehydration who has developed hypovolemic shock. Which of the following lab 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

B. Hct 55%

A nurse is employing a thorough, systemic method while obtaining objective data about a client. Through which of the following methods should the nurse collect this information? A. Health history B. Physical examination C. review of systems D. Interview

B. Physical examinatoin

A nurse is explaining Piaget's theory of cognitive devlopment to a group of daycare providers for employees children at an acute care facility. Which of the following activities should the nurse include as an example of concrete operational thinking? A. Playing in the sand B. Playing dress up with old clothes C. Collecting and trading game cards D. Describing interpersonal relationships

C. Collecting and trading game cards

A nurse is talking with a client whose provider recently informed him of terminal pancreatic cancer. When the client reports that he understands the full impact of this diagnosis, the nurse should identify that the client is in which of the following stages of dying? A. Anger B. Bargaining C. Depression D. Aceptance

C. Depression

A nurse is caring for a client who is receiving a fluid infusion through a peripheral IV catheter. The nurse notes that the area of the ar immediately surrounding the insertion site is red and feels warm. Which of the following actions should the nurse take? A. Change the infusion tubing B. Flush the IV catheter C. Remove the IV catheter D. Apply a cool compress to the site

C. Remove the IV catheter

A nurse is caring for a client who is receiving IV fluid replacement. Which of the following finding should the nurse identify as infiltration of the IV infusion site? A. Redness at the IV catheter entry site B. Palpable cord along the vein used for the infusion C. Taut skin around the iv catheter site that is cool to the touch D. Bleeding at the IV insertion site

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

A nurse is administering an IM injection to a 5 month old infant. Which of the following injection sites should the nurse use? A. Deltoid B. Ventrogluteal C. Vastus lateralis D. Dorsogluteal

C. Vastus lateralis

A nurse is caring for a middle aged adult client. The nurse should evaluate the client for progress toward which of the following developmental tasks? a. Managing a home B. Establishign a sense of self in the adult world C. Forming new friendships D. Ceasing to compare personal identity with others

D. Ceasing to compare personal identity with others

A nurse is performing a comprehensive physical assessment of a client. The nurse should use inspection to asses which of the following? A. Liver size B. Pedal edmea C. Skin texture D. Gait

D. Gait

A nurse is evaluating the development of a group of clients. According to Erikson, the development task of intimacy vs. isolation occurs during which of the following stages of development? A. Middle adulthood B. Adolescence C. Childhood D. Young adulthood

D. Young adulthood

A nurse is planning to document care provided for a client. Which of the following abbreviations should the nurse use? A. BT for bedtime B. SC for subcutaneously C. PC for after meals D. HS for half-strength

C. PC for after meals

A nurse is leading an education session about disposing of biohazardous materials. Which of the following should the nurse include in the teaching? A. use isopropyl alcohol to clean blood spills B. Discard empty blood bags in a bedside trash can. C. Break used needles before discarding. D. Place soiled linen in a single linen bag.

D. Place soiled linen in a single linen bag.

A nurse is performing an otoscopic exam of a clients right ear. The light reflex is visible in the right lower quadrant of the tympanic membrane. Which of the following actions should the nurse take in response to this finding? A. Obtain an audiology referral B. Document this as an expected finding C. Irrigate the ear with warm water D. Document mild inflammation

B. Document this as an expected finding.

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

A. Hydrocolloid

A nurse is collecting a urine specimen for culture and sensitivity for a client who has a urinary tract infection. The client has an indwelling urinary catheter in place. Which of the following actions should the nurse take? A. Withdraw the specimen from the drainage bag. B. Cleanse the collection port with soap and water C. Place the specimen in a clean specimen cup D. Clamp the tubing below the collection port.

D. Clamp the tubing below the collection port

A nurse is preparing to administer oral pheytoin to a client who has a seizure disorder. Before administering the medication which of the following actions should the nurse take? A. Document the administration of the medication B. Count the amount of available medication on hand and sign for it C. Measure the clients respiration rate D. Check the medication dose and the clients identification

D. Check the medication dose and the clients identification

A nurse is assessing a client for conductive hearing loss. When using the Rinne test, which of the following results should the nurse identify as an indication that the client has conductive hearing loss of the left ear? A. Air conduction is less than bone conduction in the left ear B. Air conduction is greater than bone conduction in the left ear C. Sound is lateralizng to the right ear D. Sound is lateralizing in the left ear

A. Air conduction is less than bone conduction in the left ear

A nurse is performing a neurological assessment for a client. By asking the client to stick out his tongue, which of the following cranial nerves is the nurse testing? A. Cranial nerveXII B. Cranial nerve X C. Cranial nerve VIII D. Cranial nerve V

A. Cranial nerve XII

A nurse is removing PPE after performing a procedure for a client who requires isolation precautions. Which of the following times of PPE should the nurse remove first? A. Gloves B. Gown C. Eyewear D. Mask

A. Gloves

As a nurse is preparing to administer liquid medication from a bottle to a client. Which of the following actions should the nurse take? A. Hold the medication bottle with the label against the palm of the hadn when pouring B. Place the cap with the inside facing down on the hard surface C. Fill the cup until the medication is even with the edge of the dosage scale D. Pour any excess liquid back into the bottle after measuring

A. Hold the medication bottle with the label against the palm of the hand when pouring

A nurse is assessing a client who is experiencing stress and anxiety regarding a recent diagnosis. Which of the following finding should the nurse expect? A. Increased bp B. decreased blood glucose level C. Decreased oxygen use D. increased gastrointestinal motility

A. Increased bp

A nurse is assessing the pH of a clients gastric fluid to confirm the placement of an NG tube in the stomach. Which of the following pH values should the nurse expect? A.6 B. 2 C. 10 D. 8

B. 2 (expected range 0-4)

A nurse is teaching a client who is post op how to use a incentive spiromter. Which of the following instructions should the nurse include? A. Blow into the spirometer to elevate the balls in the device B. Cough deeply after each use C. Clean the mouthpice with an alcohol swab after each use D. Use the spirometer every 8 hrs

B. Cough deeply after each use

A nurse is caring for a client who is postop following a vaginal hysterectomy and asks for a drink. Her postop diet prescription states "clear liquids, advance diet as tolerated". Which of the following responses should the nurse make? A. A lunch tray should be here within the hour B. I am going to listen to your abdomen C. I'll get you some water to drink D. Lets wait a bit so you don't feel sick.

B. I am going to listen to your abdomen

A nurse is assessing a client who reports nausea and vomiting for.2 days. Which of the following findings whould indicate to the nurse that the client is experiencing fluid volume deficit? A. Decreased urine specific gravity B. Increased heart rate C. Decreased hematocrit D. Increased skin tugor

B. Increased heart rate

A nurse is caring for a client who is scheduled to receive transcutaneous electrical nerve stimulation (tens) for pain management. The client asks the nurse how a tens unit helps relieve pain. Whch of the following responses should the nurse make? A. It provides a distraction from the pain B. It modulates the transmission of the pain impulse C. It promotes increased circulatoin to the painful area D. It elicits a relaxation response

B. It modulates the transmission of the pain impulse

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

A nurse is preparing to administer an IM injection to a client who is overweight. Which of the following sites should the nurse select for the injectoin? A. Lower medial quadrant of the buttock near the coccyx B. Side hip between the iliac crest and anterior iliac spine C. Tissue of the posterior upper arm D. Lower inner thigh 4 finger widths above the patella

B. Side hip between the iliac crest and anterior iliac spine

As part of a neurological exam, a nurse instructs a client to keep his eyes closed, places an object in his hand, and asks him to identify the object. Which of the following abiliites is the nurse evaluating with this technique? A. Gustation B. Sterognosis C. Proprioception D. Kinesthesia

B. Steriognois

A nurse is caring for an older adult client who has an the ear canal hearing aid. The client states that the hearing aid is making a whistling sound. The nurse should identify which of the following factors as the source of the sound? A. Low battery power B. Excessive wax in the ear canal C. A volume setting that is too low D. A crack in the ear tube

B. excessive wax in the ear canal

A nurse on a mental health unit is preparing to terminate teh nurse client relationship with a client who is no longer requires care. Which of the following concepts should the nurse and client discuss in the termination phase of the relationship? A. loss B. trust c. self-disclosure d. risk taking

B. trust

A nurse on rehab unit is preparing to transfer a client who is unable to walk from a bed to a wheelchair. Which of the following techniques should the nurse use? A. Stand toward the clients stronger side B. Instruct the client to lean backward from the hips C. Place the wheelchair at a 45 degree angle to the bed D. Assume a narrow stance with the feet 15cm apart

C. Place the wheelchair at a 45 degree angle to the bed

A nurse is preparing to irrigate a clients wound. Which of the following actions should the nurse take? A. use a 10ml syringe B. Attach a 22 gauge catheter to the syringe C. Warm the irrigating solution to 37 degrees D. Administer an analgesic 10 min before the irrigation

C. Warm the irrigating solution to 37 degrees

A nurse is examining a client for signs of costovertebral angle tenderness. The nurse should place the client in which of the following positions for evaluation? A. Sims B. supine c. sitting d. standing

C. sitting

A nurse in the emergency department is caring for a client who has abdominal trauma. Which of the following assessment finding sshould the nurse identify as an indication of hypovolemic shock? A. Warm, dry skin B. increased urinary output C. Tachycardia D. Bradypnea

C. tachycardia

A nurse is reviewing a clients lab results and notes a WBC of 3,600/mm3. The nurse should identify this result as which of the following conditions? A. Leukoplakia B. Leukemia C. Leukocytosis D. Leukopenia

D. Leukopenia (there is a decrease in production of WBC's)

A nurse is caring for a client who has a cuffed endotracheal tube in place. The nurse should identify that the purpose of inflating the cuff includes which of the following? (select all that apply) A. Allowing the client to speak B. Stabilizing the position of the tube C. Preventing aspiration of secretions D. Preventing air leaks E. Preventing tracheal injury

B, C, D

A nurse is caring for a client who is receiving a blood transfusion. The client reports flank pain, and the nurse notes reddish brown urin in the clients urinary catheter bag. The nurse recognizes these manifestations as which of the following types of transfusion reactoins? A. Hemolytic B. Febrile C. Circulatory overload D. Sepsis

A. Hemolytic

A nurse is preparing to administer an otic antiobiotic to an adult client who has otitis media. Which of the following actions should the nurse plan to take? A. Hold the dropper 1cm above the ear canal during administration B. Apply pressure to the nasolacrimal duct following administration C. Place a cotton ball into the inner canal for 30 minutes following administration D. Straighten the ear canal by pulling the auricle down and back prior to administration

A. Hold the dropper 1cm above the ear canal during administration

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

B. Hold the breath for 5 sec after goal volume is reached