Nursing 1: Fundamentals Pretest A and B

A nurse manager is preparing to review medication documentation with a group of newly licensed nurses. Which of the following statements should the nurse manager plan to include in the teaching

use the complete name of the medication magnesium sulfate

A nurse is admitting a client who has varicella. Which of the following types of transmission precautions should the nurse initiate? A) Airborne B) Droplet C) Contact D) Protective Environment

A) Airborne

A nurse is caring for a client who has a terminal illness and is at the end of life. The nurse should recognize that which of the following statements by the client's partner indicates effective coping? A) I am not worried because I still have hope that he will be okay B) I am relying on support from our family during this time C) We can plan our family reunion once he recovers and comes home D) We don't see any reason to start discussing funeral arrangements now.

B) I am relying on support from our family during this time

NTK average ranges for electrolyte labs

BUN= ? Creatinine=? sodium=? potassium=?

A nurse is caring for a client who has herpes zoster and asks the nurse about the use of complementary and alternative therapies for pain control. The nurse should inform the client that this condition is a contraindication for which of the following therapies acupuncture

acupuncture The nurse should inform the client that herpes zoster, or any skin infection, is a contraindication for the use of acupuncture. An open portal on the skin's surface could increase the risk of further infection. Feverfew is a complementary and alternative therapy that helps promote wound healing. Anticoagulant therapy is a contraindication for taking feverfew. However, herpes zoster is not a contraindication for the use of this type of therapy.

A nurse has accepted a verbal prescription for three tenths of a milligram of levothyroxine IV stat for a client who has myxedema coma. How should the nurse transcribe the dosage of this medication in the clients medical record? A) .3mg B) 0.3mg C) 0.30mg D) 3/10mg

B) 0.3mg

A nurse is caring for a client who has a sodium level of 125 mEq/L. Which of the following findings should the nurse expect? A) Numbness of the extremities B) Bradycardia C) Positive Chvosteks sign D) Abdominal cramping

D) Abdominal cramping

A nurse is caring for a client who has a terminal illness and is approaching death. The client is short of breath and has noisy respirations from secretions in their airway. Which of the followinng actions should the nurse take? A) Turn the client every 2 hours B) Administer an anti-emetic every 6 hours C) Hold oral care D) Increase the rooms temperature

A) Turn the client every 2 hours

A nurse is assessing an older adult client's risk for falls. Which of the following assessments should the nurse use to identify the client's safety needs? (Select all that apply) A) Lacrimal Apparatus B) Pupil Clarity C) Appearance of bulbar conjuctivae D) Visual Fields E) Visual Acuity

B) Pupil Clarity D) Visual Fields E) Visual Acuity

A nurse is caring for a client who has an aggressive form of prostate cancer. The provider breifly discusses treatment options and leaves the client's room. When the nurse asks if the client would like to discuss any concerns, the client declines. Which of the following statements should the nurse make? A) I will return shortly after I document this in your record B) Most men live a long time with prostate cancer C) I am available to talk if you should change your mind D) I will make a referral to a cancer support group for you

C) I am available to talk if you should change your mind

A nurse is caring for a client receiving fluid through a peripheral IV catheter, which of the following findings at the IV site should the nurse identify as infiltration? A) purulent exudate B) Warmth C) Skin blanching D) Bleeding

C) Skin blanching

A nurse is caring for a client who is postoperative. When the nurse prepares to change her dressing, she says, " every time you change my bandage, it hurts so much." Which of the following interventions is the nurses priority action? A) Encourage the client to relax and take deep breathes during the dressing change B) Educate the client about the importance of dressing change to prevent infection C) Assist the client to a comfortable position for the dressing change D) Administer pain medication 45 minutes before changing the clients dressing

D) Administer pain medication 45 minutes before changing the clients dressing

The nurse is admitting a client who is having an exacerbation of heart failure. In planning this client's care, when should the nurse initiate discharge planning? A) During the admission process B) As soon as the client's condition is stable C) During the initial team conference D) After consulting with the client's family

A) During the admission process

A nurse is providing discharge instructions to a client who will be using a walker. Which of the following client statements indicates an understanding of the teaching? A) I can place an extension cord across my living room to plug in my television B) I will hire someone to trim the tree that hangs low over the stairs of my front porch C) I will place my alarm clock on my dresser across the room D) I will replace the old throw rug in my kitchen with a new one

B) I will hire someone to trim the tree that hangs low over the stairs of my front porch

A nurse is caring for a group of clients. Which of the following actions should the nurse take to prevent the spread of infection? A) Carry a clients soiled linen out of the room in a mesh linen bag B) Place a client who has tuberculosis in a room with negative pressure airflow C) Provide disposable plates and utensils for a client who is HIV positive D) Dispose of a client's blood saturated dressing in a trash bag inside another trash bag

B) Place a client who has tuberculosis in a room with negative pressure airflow client who has tuberculosis requires airborne precautions, which include placing the client in a room that has negative-pressure airflow to reduce the risk of infection transmission.

A nurse is educating a client who has a terminal illness about declining resuscitation in a living will. The client asks, "What would happen if I arrived at the emergency department and I had difficulty breathing?" Which of hte following responses should the nurse make? A) We would consult the person appointed by your health care proxy to make decisions B) We would give you oxygen through a tube in your nose C) You would be unable to change your previous wishes about your care D) We would insert a breathing tube while we evaluate your condition

B) We would give you oxygen through a tube in your nose

A home health nurse is performing a follow up visit for a client who has a gastrostomy tube through which they receive intermittent feedings and medications. The client has recently developed diarrhea. Which of the following findings should the nurse identify as a possible cause of the diarrhea? A) The client is receiving formula at room temperature B) The feedings infuse at a slow continuous drip over 8 hours each night C) The clients caregiver washes out the feeding bag with warm water every 24 hours D) The clients caregiver flushes the tubing bag with water before and after administering medication

C) The clients caregiver washes out the feeding bag with warm water every 24 hours

A nurse is admitting a client who has an abdominal wound with a large amount of purulent drainage. Which of the following types of transmission precautions should the nurse initiate? A) Protective environment B) Airborne Precautions C) Droplet precautions D) Contact precautions

D) Contact precautions

A charge nurse is discussing the responsibility of nurses caring for clients who have a C. diff infection Which of the following information should the nurse include in the teaching? A) Assign the client to a room with a negative airflow system B) Use alcohol-based hand sanitizer when leaving the clients room C) Clean contaminated surfaces in the clients room with a phenol solution D) Have family members where a gown and gloves when visiting

D) Have family members where a gown and gloves when visiting

A nurse is assessing a client who reports increased pain following physical therapy. Which of the following questions should the nurse ask when assessing the quality of the patient's pain? A) Is your pain constant or intermittent B) What would you rate your pain on a scale of 0-10 C) Does the pain radiate D) Is your pain sharp or dull

D) Is your pain sharp or dull asking the client whether the pain is sharp, dull, crushing, throbbing, aching , burning, electric like, or shooting helps determine the quality of pain.

A nurse receives report about a client who has 0.9% sodium chloride infusing IV at 125 mL/hr. When the nurse performs the initial assessment, he notes that the client has received only 80 ml over the last 2 hours. Which of the following actions should the nurse take? A) Reposition the client B) Document the client's IV intake in the medical record C) Request a new IV fluid prescription D)

D) check the tubing for obstruction The first action the nurse should take using the nursing process is to assess the client. If checking the IV tubing and verifying an obstruction, the nurse might be able to facilitate the flow of fluid through the tubing. This could re-establish the infusion rate the provider prescribed.

A nurse is caring for a client who has a prescription 5 units of regular insulin and 10 units of NPH insulin to mix together and to administer subcutaneously. Determine the correct order of steps for this procedure. 1. Inject 5 units of air into the bottle of regular insulin 2. Withdraw the correct dose of NPH insulin from the bottle 3. Inject 10 units of air into the bottle of NPH insulin 4. Withdraw the correct dose of regular insulin from the bottle

3, 1,4,2

A nurse is assessing a client's readiness to learn about insulin self-administration. Which of the following statements should the nurse identify as an indication that the client is ready to learn? A) "I can concentrate best in the morning" B) "It is difficult to read the instructions because my glasses are at home" C) "I'm wondering why I need to read this."

A) "I can concentrate best in the morning" The client's statement indicates a readiness to learn because he is verbalizing the best time for him to learn.

A nurse is assessing a client's readiness to learn about insulin administration. Which of the following statements should the nurse identify as an indication that the client is ready to learn? A) "I can concentrate best in the morning." B) "It is difficult to read the instructions because my glasses are at home." C) "I'm wondering why I need to learn this." D) "You will have to talk to my wife about this."

A) "I can concentrate best in the morning."

A nurse is preparing to administer enoxaparin subcutaneously to a client. Which of the following actions should the nurse take? A) Administer the medication with the needle at a 45 degree angle B) Administer the medication into the client's non-dominant arm C) Pull the clients skin laterally or downward prior to administration D) Massage the injection site after administration

A) Administer the medication with the needle at a 45 degree angle

A nurse is planning care for a client who has had a stroke, resulting in aphasia and dysphagia. Which of the following tasks should the nurse assign to an assistive personnel (AP)? Select all that apply A) Assist the client with a partial bed bath B) Measure the clients blood pressure after the nurse administers an anti-hypertensive medication C) Test client's swallowing ability by providing thickened liquids D) Use a communication board to ask what the client wants for lunch E) Irrigate the client's indwelling urinary catheter

A) Assist the client with a partial bed bath B) Measure the clients blood pressure after the nurse administers an anti-hypertensive medication D) Use a communication board to ask what the client wants for lunch

A nurse is administering IV fluid to an older adult client. The nurse should perform which priority assessment to monitor for adverse effects? A) Auscultate lung sounds B) Measure urine output C) Monitor blood pressure readings D) Monitor serum electrolyte levels.

A) Auscultate lung sounds

A nurse is assessing an adult client who has been immobile for the past 3 weeks. The nurse should identify that which of the following findings requires further intervention? A) Erythema on pressure points B) Lower extremity pulse strength of 2+ C) Fluid intake of 3000 mL per day D) Bowel movement every other day

A) Erythema on pressure points

A nurse is caring for a child who has a prescription for a blood transfusion. The clients parents refuse the treatment due to their religious beliefs. Which of the following actions should the nurse take? A) Examine personal values about the issue B) Tell the parents that this is a necessary procedure C) Inform the parents that the staff does not require their concent D) Contact a spiritual support person to explain the importance of the procedure.

A) Examine personal values about the issue

A nurse in a long term care facility is caring for a client who dies during the nurses shift. Identify the sequence in which the nurse should perform the following steps. A) Obtain the pronouncement of death from the provider B) Ask the clients family members if they would like to view the body C) Place a name tag on the body D) Wash the body E)Remove tubes and indwelling lines

A) Obtain the pronouncement of death from the provider E) Remove tubes and indwelling lines D) Wash the body B) Ask the clients family members if they would like to view the body C) Place a name tag on the body

A nurse on a medical-surgical unit is caring for a client who has a new prescription for wrist restraints. Which of the following actions should the nurse take? A) Pad the clients wrists before applying the restraints B) Evaluate the client's circulation every 8 hours after apllication C) Remove the restraints every 4 hours to evaluate the clients status. D) Secure the restraint ties to the beds side rails

A) Pad the clients wrists before applying the restraints The use of restraints without padding can abrade the client's skin, resulting in client injury. The nurse should remove the restraints at least every 2 hr to reposition the client and assess needs for hygiene and toileting.

A nurse is administering an otic medication to an older adult client. Which of the following actions should the nurse take to ensure that the medication reaches the inner ear? A) Press gently on the tragus of the client's ear B) Pack a small piece of cotton in the client's ear canal C) Move the clients auricle down and back toward her head D) Tilt the client's head backward for 5 minutes

A) Press gently on the tragus of the client's ear Inserting a piece of cotton into the meatus of the canal could damage the ear. If cotton is necessary, the nurse should place it into the outer portion of the ear canal and not push it inward. For an adult client, the nurse should move the auricle upward and backward or upward and outward to straighten the ear canal.

A nurse is caring for a client who has dementia. Which of the following interventions should the nurse take to minimize the risk for injury to the client? A) Use a bed exit alarm system B) Raise four side rails while the client is in bed C) Apply one soft wrist restraint D) Dim the lights in the client's room

A) Use a bed exit alarm system

a nurse is preparing an education program for staff about advocacy. Which of the following information should the nurse include

Advocacy is a key component of professional nurses' code of ethics. As a client advocate, the nurse ensures clients' safety, health, and rights, including the right to privacy, confidentiality, and refusal of care.

A nurse is caring for a client who has a respiratory infection. Which of the following techniques should the nurse use when performing nasotracheal suctioning to the client? A) Insert the suction catheter while the client is swallowing B) Apply intermittent suction while withdrawing the catheter C) Place the catheter in a location that is clean and dry for later use. D) Hold the suction catheter with her clean, non-dominant hand

B) Apply intermittent suction while withdrawing the catheter

A nurse is caring for a client who has pharyngeal diptheria. Which of the following types of transmission precautions should the nurse indicate? A) Contact B) Droplet C) Airborne D) Protective

B) Droplet Droplet precautions are a requirement for clients who have infections that spread via droplet nuclei that are larger than 5 microns in diameter, including rubella, meningococcal pneumonia, and streptococcal pharyngitis. The nurse should wear a mask when providing care or when within 1 m (3 feet) of the client who has a disorder requiring droplet precautions.

A nurse is assessing four adult clients. Which of the following physical assessment techniques should the nurse use? A) Use the Face, Legs, Activity, Cry and Consolability (FLACC) pain rating scale for a client who is experiencing pain B) Ensure the bladder of the blood pressure cuff surrounds 80% of the clients arm C) Obtain an Apical heart rate by auscultating at the 3rd intercostal space , left of the sternum D) Palpate the clients abdomen before auscultating bowel sounds

B) Ensure the bladder of the blood pressure cuff surrounds 80% of the clients arm

A nurse is initiating a protective environment for a client who has had an allogeneic stem cell transplant. Which of the following precautions should the nurse plan for this client? A) Make sure the client's room has at least 6 air exchanges per hour B) Make sure the client wears a mask when outside the room if there is construction in the area. C) Place the client in a private room with negative pressure airflow D) Wear an N95 when giving the client direct care

B) Make sure the client wears a mask when outside the room if there is construction in the area. An allogeneic stem cell transplant compromises the client's immune system, greatly increasing the risk for infection. The client will need protection from breathing in any pathogens in the environment. A protective environment requires at least 12 air exchanges per hour. The nurse should place the client in a private room that provides positive-pressure airflow.

A nurse is reviewing evidence-based practice principles about administration of oxygen therapy with a newly licensed nurse. Which of the following actions should the nurse include? A) Regulate the flow rate by aligning the rate with the top of the ball inside the flow meter. B) Regulate oxygen via nasal cannula at a flow rate of no more than 6L/min C) Make sure the reservoir bag of a partial rebreathing mask remain deflated D) Use petroleum jelly to lubricate the client's nares, face and lips

B) Regulate oxygen via nasal cannula at a flow rate of no more than 6L/min Evidence-based practice supports a flow rate of 1 to 6 L/min via nasal cannula. Rates above 6 L/min have a drying effect and force clients to swallow air excessively without increasing their fraction of inspired oxygen (FiO2).

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? A) Rinse the feeding bag with water between feedings B) Tell the client to keep the head of the bed elevated at least 30 degrees C) Make sure the enteral formula is at room temperature D) Wipe the top of the formula can with alcohol

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

A nurse is performing a home safety assessment for a client who is receiving supplemental oxygen. Which of the following observations should the nurse identify as proper safety protocol? A) The client uses a wool blanket on their bed B) The client identifies the location of a fire extinguisher C) The client stores an extra oxygen tank on its side under the bed D) The client has a weekly inspection checklist for oxygen equipment

B) The client identifies the location of a fire extinguisher The client or caregiver should inspect oxygen equipment daily.

A nurse is caring for a client who asks about the purpose of advance directives. Which of the following statements should the nurse make? A) They allow the court to overrule an adult clients refusal of medical treatment B) They indicate the form of treatment a client is willing to accept in the event of a serious illness C) They permit a client to withhold medical information from healthcare personnel D) They allow healthcare personnel in the emergency department to stabilize a client's condition

B) They indicate the form of treatment a client is willing to accept in the event of a serious illness

A nurse is caring for a client who asks about the purpose of advanced directives. Which of the following statements should the nurse make? A) "They allow the court to overrule an adult client's refusal of medication treatment" B) They indicate the form of treatment a client is willing to accept in the event of a serious illness C) They permit a client to withhold medical information from healthcare personnel D) They allow health care personnel in the emergency department to stabilize a clients condition

B) They indicate the form of treatment a client is willing to accept in the event of a serious illness

A nurse is teaching a client and his family how to care for the clients tracheostomy at home. Which of the following instructions should the nurse include in the teaching? A) Remove the outer cannula cautiously for routine cleaning B) Use tracheostomy covers when outdoors C) Use sterile technique when performing tracheostomy care at home D) Cleanse irritated skinn with full strength hydrogen peroxide

B) Use tracheostomy covers when outdoors

A nurse in a surgical suite notes documentation on a client's medical record that he has a latex allergy. In preparation for the clients procedure, which of the following precautions should the nurse take? A) Ensure sterilization of non-disposable items with ethylene oxide. B) Wrap monitoring cords with stockinette and tape them in place C) Cleanse latex ports on IV tubing with chlorhexidine before injecting medicine D) Wear hypoallergenic latex gloves that contain powder.

B) Wrap monitoring cords with stockinette and tape them in place

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? A)"I'll get a blood sample from you and send it for a screening test." B) "Beginning at age 60, you should have a colonoscopy" C) "You should have a fecal occult blood test every year." D) "The recommendation is to have a sigmoidoscopy every 10 years."

C) "You should have a fecal occult blood test every year."

A nurse is performing a skin assessment for a client who expresses concern about skin cancer. Which of the following findings should the nurse identify as a potential indication of a skin malignancy? A) A lesion with uniform pigmentation B) New appearance of petechiae C) A mole with an asymmetrical appearance D) The presence of a papule

C) A mole with an asymmetrical appearance

A nurse is providing discharge teaching to a client about self-administering heparin. Which of the following instructions should the nurse include in the teaching? A) Insert the needle at a 15 degree angle B) Aspirate for blood return prior to administration C) Administer the medication into the abdomen D) Massage the site following the injection

C) Administer the medication into the abdomen

A nurse is assessing a client who has been on bed rest for the past month. Which of the following findings should the nurse identify as an indication that the client has developed thrombophlebitis? A) Bladder distention B) Decreased blood pressure C) Calf swelling D) Diminished bowel sounds

C) Calf swelling

A nurse is admitting a new client. Which of the following actions should the nurse take while performing medication reconciliation? A) Verify the client's name on their identification bracelet with the medication administration record B) Call the pharmacy to determine whether the client's medication are available C) Compare the clients home medications with the providers prescriptions D) Place the client's home medications in a secure location

C) Compare the clients home medications with the providers prescriptions ntk what mediation reconciliation is The nurse should compare the client's home medications with the provider's prescriptions when performing medication reconciliation.

A client who is postoperative is verbalizing pain as a 2 on a pain scale of 0-10. Which of the following statements should the nurse identify as an indication that the client understands the preoperative teaching she received about pain management? A) I think I should take my pain medication more often , since it is not controlling my pain B) Breathing faster will help me keep my mind off of the pain C) It might help me to listen to music while I'm in bed D) I don't want to walk today because I have some pain.

C) It might help me to listen to music while I'm in bed

A nurse is talking with an older adult client who is contemplating retirement. The client states, " I keep thinking about how much I enjoy my job. I'm not sure I want to retire." Which of the following responses should the nurse make? A) You would have so much more time to spend with your family B) You should consider getting a part time job or doing volunteer work C) Lets talk about how the change in your job status will effect you D) Why wouldn't you want to retire and relax

C) Lets talk about how the change in your job status will effect you

A nurse is caring for a client that is postoperative following a knee arthroplasty and requires the use of thigh-high sequential compression sleeves. Which of the following actions should the nurse take? A) Assist the client into a prone position B) Place a sleeve over the top of each leg with the opening at the knee C) Make sure two fingers can fit under the sleeve D) Set the ankle pressure at 65 mm Hg

C) Make sure two fingers can fit under the sleeve

A nurse is assisting a client who is postoperative with the use of an incentive spirometer. Into which of the following positions should the nurse place the client? A) Side-lying B) Supine C) Semi-fowlers D) Trendelenburg

C) Semi-fowlers

The nurse is evaluating the client's use of a cane. Which of the following actions should the nurse identify as an indication of correct use? A) The top of the cane is parallel to the client's waist B) When walking, the client moves the cane 46 cm (18 in) forward C) The client holds the cane on the stronger side of the body D) The client moves her stronger limb forward with the cane.

C) The client holds the cane on the stronger side of the body

A nurse is planning strategies to manage time effectively for client care. Which of the following strategies should the nurse implement? A) Continue client care tasks when caring for multiple clients B) Wait until the end of the shift to document client care C) Use the planning step of the nursing process to prioritize client care delivery D) Allow for interruptions in tasks to discuss client care issues with colleagues

C) Use the planning step of the nursing process to prioritize client care delivery Setting up a list of goals and tasks to perform for clients can help the nurse set care priorities and plan tasks accordingly. The priority to-do list is an efficient tool for optimal time management.

A nurse is administering 1L of 0.9% sodium chloride to a client who is postoperative and has fluid volume deficit. Which of the following changes should the nurse identify as an indication that the treatment was successful? A) Increase in hematocrit B) Increase in respiratory rate C) decrease in heart rate D) decrease in capillary refill time

C) decrease in heart rate

A nurse is admitting a client who has an abdominal wound with a large amount of purulent drainage. Which of the following types of transmission precautions should the nurse indicate? A) Protective environment B) Airborne C) Droplet D) Contact

D) Contact

A nurse is preparing to apply a dressing for a client who has a stage 2 pressure injury. Which of the followinng types of dressing should the nurse use? A) Alginate B) Gauze C) Transparent D) Hydrocolloid

D) Hydrocolloid Hydrocolloid dressings promote healing in stage 2 pressure injuries by creating a moist wound bed.

A nurse is caring for a client who is postoperative and is exhibiting signs of hemorrhagic shock. The nurse notifies the surgeon, who tells the nurse to continue to measure the clients vital signs every 15 minutes and to report back in one hour. Which of the following actions should the nurse take next? A) Document the providers statement in the medical record B) Complete an incident report C) Consult the facility risk manager D) Notify the nursing manager

D) Notify the nursing manager The greatest risk to the client is not receiving timely intervention for a deterioration in physiological status; therefore, the next action the nurse should take is to activate the chain of command to ensure that the client receives the necessary care.

A nurse is caring for a client who has diarrhea due to shigella. Which of the following precautions should the nurse implement for this client? A) Have the client wear a mask when receiving visitors B) Limit the clients time with visitors to no more than 30 minutes per day C) Assign the client to a room with negative pressure airflow exchange D) Wear a gown when caring for the client

D) Wear a gown when caring for the client

A nurse is preparing to administer 0.9% sodium chloride 750 ml IV to infuse over 7 hours. The nurse should set the infusion pump to deliver how many ml/hr? (Round to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero)

107 ml/hr

A nurse is using an open irrigation technique to irrigate a clients indwelling urinary catheter. Which of the following actions should the nurse take

subtract the amount of irritant used from the client's urine output The nurse should calculate the fluid used for irrigation and subtract it from the client's total urinary output.

A nurse is planning to insert a peripheral IV catheter for an older adult client. Which of the following actions should the nurse plan to take

The nurse should place the client's arm in a dependent position because the veins will dilate due to gravity.

A nurse in a long-term care facility is planning to perform hygiene care for a new resident. Which of the following assessment questions is the nurse's priority before beginning this procedure? a) "When do you usually bathe, in the morning or the evening?" b) "Do you prefer a bath or shower?" c) "At what temperature do you prefer your bath water?" d) Are you able to help with your hygiene care?"

d) Are you able to help with your hygiene care?"