Nursing Fundamental Dynamic Quiz

A nurse is collecting data for the health history of a client who is postoperative and has paralytic ileus. Which of the following findings should the nurse expect?

Absent bowel sounds with distention. Explanation: Paralytic ileus is an immobile bowel. With this disorder, bowel sounds are absent and the abdomen is distended.

A nurse is reviewing adult cardiopulmonary resuscitation (CPR) with a newly licensed nurse. Which of the following steps should the nurse identify as the first response when performing CPR?

Confirm unresponsiveness. Explanation: The nurse should apply the nursing process priority-setting framework. The nurse can use the nursing process to plan client care and prioritize nursing actions. Each step of the nursing process builds on the previous step, beginning with assessment or data collection. Before the nurse can formulate a plan of action, implement a nursing intervention, or notify a provider of a change in the client's status, she must first collect adequate data from the client. Assessing or collecting additional data will provide the nurse with knowledge to make an appropriate decision. Establishing unresponsiveness is required before beginning CPR. If a client is unresponsive, the nurse should activate the emergency response team.

A nurse on a medical-surgical unit is caring for a client. Which of the following actions should the nurse take first when using the nursing process?

Obtain client information. Explanation: The nurse should apply the nursing process priority-setting framework. The nurse can use the nursing process to plan client care and prioritize nursing actions. Each step of the nursing process builds on the previous step, beginning with data collection. Before the nurse can formulate a plan of action, implement a nursing intervention, or notify a provider of a change in the client's status, she must first collect adequate data from the client. Collecting additional data will provide the nurse with knowledge to make an appropriate decision.

A nurse is reinforcing preoperative teaching with a client who is scheduled for arthroplasty in the next month and might require a blood transfusion. The client expresses concern about the risk of acquiring an infection from the blood transfusion. Which of the following suggestions should the nurse make?

"Donate autologous blood before the surgery." Explanation: Autologous blood transfusion is the collection and reinfusion of the client's own blood. With preoperative autologous blood donation, the blood is drawn from the client 3 to 5 weeks before an elective surgical procedure and stored for transfusion at the time of the surgery. Autologous blood is the safest form of blood transfusion; exclusive use of a client's own blood eliminates exposure to transfusion-transmitted infection.

A nurse in an oncology clinic is collecting data for a client who is undergoing treatment for ovarian cancer. Which of the following statements by the client indicates she is experiencing psychological distress?

"I keep having nightmares about my upcoming surgery." Explanation:The nurse should recognize that nightmares and sleep disturbances are manifestations of anxiety and post-traumatic stress disorder. These indicate that the client is at risk for experiencing psychological distress.

A nurse is reinforcing teaching with an older adult client who has constipation. Which of the following statements should the nurse include in the teaching?

"Sit on the toilet 30 minutes after eating a meal." Explanation: Increased peristalsis occurs after food enters the stomach. Sitting on the toilet 30 min after eating a meal, regardless of feeling the urge to defecate, is a recommended method of bowel retraining to treat constipation.

A nurse is instructing an assistive personnel (AP) about proper hand hygiene. Which of the following statements by the AP indicates an understanding of the teaching?

"There are times I should use soap and water rather than an alcohol-based hand rub to clean my hands." Explanation: While alcohol-based hand rubs are as effective as soap and water in providing proper hand hygiene, the Center for Disease Control and Prevention recommends washing hands with soap and water at certain times, such as when the hands are visibly soiled with dirt or body fluids.

A nurse observes an assistive personnel (AP) preparing to obtain blood pressure with a regular size cuff for a client who is obese. Which of the following explanations should the nurse give the AP?

"Using a cuff that is too small will result in an inaccurately high reading." Explanation: Blood pressure cuffs come in various sizes, and the correct size cuff is necessary to obtain a reliable measurement. Blood pressure readings can be falsely high if the cuff is too small for the client.

A nurse is caring for an older adult client who becomes agitated when the nurse requests that the client's dentures be removed prior to surgery. Which of the following responses should the nurse make?

"What worries you about being without your teeth?" Explanation: This response by the nurse is therapeutic because it validates the client's feelings of agitation and seeks a reason for it.

A nurse is caring for a child who is postoperative following a tonsillectomy. Which of the following actions should the nurse take?

Administer analgesics to the child on a routine schedule throughout the day and night. Explanation: To soothe the client's throat following a tonsillectomy, the nurse should administer pain medication routinely around the clock. The nurse can provide the medication rectally or intravenously to avoid the oral route.

A nurse is planning weight loss strategies for a group of clients who are obese. Which of the following actions by the nurse will improve the clients' commitment to a long-term goal of weight loss?

Attempt to increase the clients' self-motivation. Explanation: Motivation to learn is important in improving a client's commitment to achievement of a health goal, as well as increasing the amount and speed of learning.

A nurse is drawing blood for laboratory testing from a client that results in a blood spill on her gloved hand. The client has no documented bloodstream infection. Which of the following actions should the nurse take?

Carefully remove the gloves and follow with hand hygiene. Explanation: Standard precautions require the use of gloves and hand hygiene in the care of all clients.

A nurse is measuring vital signs for a client and notices an irregularity in the pulse. Which of the following actions should the nurse take?

Count the apical pulse rate for 1 full minute, and describe the rhythm in the chart. Explanation: If the peripheral pulse is irregular, the nurse should auscultate the apical pulse for 60 seconds to obtain an accurate rate. The nurse should document the irregularity in the client's medical record.

A nurse on a medical surgical unit is admitting a client. Which of the following information should the nurse document in the client's record first?

Data collection for the client Explanation: The nurse should apply the nursing process priority-setting framework. The nurse can use the nursing process to plan client care and prioritize nursing actions. Each step of the nursing process builds on the previous step, beginning with assessment or data collection. Before the nurse can formulate a plan of action, implement a nursing intervention, or notify a provider of a change in the client's status, she must first collect adequate data from the client. Assessing or collecting additional data will provide the nurse with knowledge to make an appropriate decision.

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?

Disconnect the machine and measure the blood pressure manual every 15 minutes. Explanation: If the nurse questions the reliability of the monitoring equipment, a manual process should be used. Also, malfunctioning equipment can pose a safety risk for the client, so it must be tagged and removed.

A nurse is collecting data for a client who has decreased circulation in his left leg. Which of the following actions should the nurse take first?

Evaluate pedal pulses. Explanation: For a client who has decreased circulation in the leg, evaluating pedal pulses is critical in order to determine adequate blood supply to the foot. The nurse should apply the safety and risk reduction priority-setting framework when caring for this client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. This framework assigns priority to the factor posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's Hierarchy of Needs, the ABC priority-setting framework, or nursing knowledge to identify which risk poses the greatest threat to the client.

A nurse is collecting data for a client who has had diarrhea and decreased urination for several days. Which of the following actions should the nurse take to determine if the client is dehydrated?

Grasp a skin fold on the chest under the clavicle, release it, and note whether it springs back. Explanation: The nurse should use this technique for collecting data on skin turgor. If the client has good turgor and is properly hydrated, the skin will immediately return to normal; with dehydration, the skin will remain tented. The nurse can also collect data on skin turgor by grasping a skin fold on the back of the forearm.

A nurse is caring for a client who requires a chest x-ray. Prior to the client being transported for the procedure, which of the following actions should the nurse take first?

Identify the client using two identifiers. Explanation: The nurse should apply the safety and risk reduction priority-setting framework when caring for this client. This framework assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's hierarchy of needs, the ABC priority-setting framework, or nursing knowledge to identify which risk poses the greatest threat to the client. Once the client's identity is determined, the nurse can then proceed with the other options. This action is the priority action because it provides for the safety of the client. It is a nursing responsibility to be certain that each client receives only what has been prescribed. The nurse must assure that the correct client is being transported for a chest x-ray.

A nurse is collecting data for an adult client. Identify the correct sequence of steps used for data collection of the abdomen. (Move the sequence of steps into the box on the right, placing them in the selected order of performance. Use all the steps.)

Inspection, Auscultation, Percussion, Palpation. Explanation: The appropriate sequence for the nurse to perform the abdominal data collection is to inspect, auscultate, percuss, and then palpate. This sequence prevents altering the bowel sounds and causing false results. The appropriate sequence for any other data collection for an adult client is inspection, palpation, percussion, and auscultation.

A nurse is receiving a client from the PACU who is postoperative following abdominal surgery. Which of the following actions should the nurse take to transfer the client from the stretcher to the bed?

Lock the wheels on the bed and stretcher. Explanation: Locking the wheels prevents the client from falling to the floor by not allowing the cart or bed to move apart or away from the client.

A nurse is preparing a client who is scheduled for a hysterectomy for transport to the operating room when the client states she no longer wants to have the surgery. Which of the following actions should the nurse take?

Notify the provider about the client decision. Explanation: Acting as the client advocate, the nurse should support the client in her decision and notify the provider.

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?

Obtaining cotton balls for the tracheostomy care Explanation: Cotton ball particles can be aspirated into the tracheostomy opening, possibly causing tracheal abscess. The charge nurse should intervene for this action.

A nurse is preparing to provide tracheostomy care for a client. Which of the following actions should the nurse take first?

Perform hand hygiene. Explanation: According to evidence-based practice, the nurse should first perform hand hygiene before touching the client or performing any skills, such as tracheostomy care. This is vital because contamination of the nurse's hands is a primary source of infection.

A nurse is obtaining the blood pressure in a client's lower extremity. Which of the following actions should the nurse take?

Place the bladder of the cuff over the posterior aspect of the thigh. Explanation: This is the correct position for the nurse to place the bladder of the cuff when measuring a lower extremity blood pressure.

A nurse on a rehabilitation 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?

Place the wheelchair at a 45° angle to the bed. Explanation: Positioning the wheelchair at a 45° angle allows the client to pivot, lessening the amount of rotation required.

A nurse is preparing to perform oral care for a client who is unresponsive. Which of the following actions should the nurse plan to take?

Raise the level of the bed. Explanation: The nurse should raise the bed to allow for the use of proper body mechanics and reduce the risk of self-injury.

A nurse is caring for an older adult client who is violent and attempting to disconnect her IV lines. The provider prescribes soft wrist restraints. Which of the following actions should the nurse take while the client is in restraints?

Remove the restraints one at a time. Explanation: The nurse should remove one restraint at a time for a client who is violent or noncompliant.

A nurse is assisting with planning a community campaign about seasonal influenza. Which of the following plans should be included as a secondary prevention strategy?

Screening groups of older adults in nursing care facilities for early influenza manifestations. Explanation: Screening older adults who have some manifestations of illness to determine if they have influenza is an example of secondary prevention. Secondary prevention is focused on preventing complications of an illness or providing care to prevent illness from becoming severe.

A nurse at a screening clinic is collecting data for a client who reports a history of a heart murmur related to aortic valve stenosis. At which of the following anatomical areas should the nurse place the stethoscope to auscultate the aortic valve?

Second intercostal space to the right of the sternum Explanation:The aortic valve is located in the second intercostal space to the right of the sternum. Aortic stenosis produces a midsystolic ejection murmur that can be heard clearly at the aortic area with the client leaning forward.

A nurse is caring for a client who is in the terminal stage of cancer. Which of the following actions should the nurse take when she observes the client crying?

Sit and hold the client's hand. Explanation: With this action, the nurse uses the therapeutic communication techniques of silence, touch, and offering of self to the client.

A nurse is caring for a client who has type 1 diabetes mellitus and is resistant to learning self-injection of insulin. Which of the following statements should the nurse make?

Tell me what I can do to help you overcome your fear of giving yourself injections Explanation: This response illustrates the therapeutic communication technique of clarifying and offering of self. It is important for the nurse to allow the client to express feelings and fears and to support the client in learning how to give the injections.

A nurse is collecting data from a client who reports abdominal pain. Further findings reveal the client has a temperature of 39.2° C (102.6° F), a heart rate of 105/min, a soft nontender abdomen, and menses overdue by 2 days. Which of the following findings should be the nurse's priority?

Temperature Explanation: Elevated temperature is an emergent physiological need which requires priority intervention by the nurse. The nurse should consider Maslow's Hierarchy of Needs, which includes five levels of priority when answering this item. The first level consists of physiological needs; the second level consists of safety and security needs; the third level consists of love and belonging needs; the fourth level consists of personal achievement and self-esteem needs; and the fifth level consists of achieving full potential and the ability to problem solve and cope with life situations. When applying Maslow's Hierarchy of Needs, the nurse should review physiological needs first. The nurse should then address the client's needs by following the remaining four hierarchal levels. However, it is important for the nurse to consider all contributing client factors, as higher levels of the pyramid can compete with those at the lower levels, depending on the situation.

A nurse is planning to obtain the vital signs of a 2-year-old child who is experiencing diarrhea and who may have a right ear infection. Which of the following routes should the nurse use to obtain the temperature?

Temporal Explanantion: The temporal artery route, while not as accurate as the rectal route for obtaining a precise body temperature, is non-invasive and can be used to obtain a temperature in a toddler who may have an ear infection and who is having diarrhea. The nurse should place the probe behind the ear if the client is diaphoretic, but should avoid placing it over an area covered with hair.

A nurse is reinforcing teaching of postoperative deep breathing and coughing exercises with a client who will have emergency surgery for appendicitis. Which of the following statements indicates a lack of readiness to learn by the client?

The client reports severe pain. Explanation: A client who is experiencing severe pain is not able to concentrate and therefore is not ready to learn a new activity.

A nurse is reinforcing teaching with a client who has heart failure about how to reduce his daily intake of sodium. Which of the following factors is the most important in determining the client's ability to learn new dietary habits?

The involvement of the client in planning the change. Explanation: According to evidence-based practice, client involvement in planning dietary changes is the most important factor in the client's ability to learn new habits.

A nurse on a medical-surgical unit is washing her hands prior to assisting with a surgical procedure. Which of the following actions by the nurse demonstrates proper surgical hand-washing technique?

The nurse washes with her hands held higher than her elbows. Explanation: The nurse who is performing a surgical hand-washing technique should wash with her hands held higher than the elbows so that water and soapsuds can drain away from the clean area toward the dirty area.

A nurse is witnessing a client signing an informed consent form for surgery. Which of the following describes what the nurse is affirming by this action?

The signature on the preoperative consent form is the client's. Explanation: The nurse acts as a witness to attest that it is the client's signature on the preoperative consent form. It is the responsibility of the provider who will perform the procedure to obtain consent by explaining the procedure along with the associated risks and benefits.

A nurse is reinforcing teaching with a group of older adults about expected changes of aging. Which of the following statements by a group member indicates that the teaching has been effective?

"I should expect my heart rate to take longer to return to normal after exercise as I get older." Explanation: Older adults experience decreased cardiac output, which causes increased pulse rate during exercise. However, the pulse rate also takes longer to return to normal after exercise.

A nurse is caring for a client who has a terminal illness. The client asks several questions about the nurse's religious beliefs related to death and dying. Which of the following actions should the nurse take?

Encourage the client to express his thoughts about death and dying. Explanation: The nurse should recognize the client's need to talk about impending death and should encourage the client to discuss his thoughts on the subject. This is the therapeutic technique of reflecting. Depending on the situation, the nurse can also share some thoughts on this topic. Self-disclosure is a communication skill that can help open lines of communication when appropriate. If the nurse does not want to share personal beliefs, the communication skills of offering self and listening to the client's thoughts are appropriate.

A nurse is auscultating the heart sounds of a client who has developed chest pain that worsens with inspiration. The nurse hears a high-pitched scratching sound with the diaphragm of the stethoscope placed at the third intercostal space of the left sternal border. Which of the following heart sounds should the nurse document?

Pericardial friction rub Explanation: A pericardial friction rub has a scratching, grating, or squeaking leathery sound. It tends to be high frequency and best heard with the diaphragm of the stethoscope at the third intercostals space of the left sternal border. A pericardial friction rub is a manifestation of pericardial inflammation and can be heard with infective pericarditis, myocardial infarction, following cardiac surgery or trauma, and with some autoimmune problems, such as rheumatic fever. The client who develops pericarditis typically has chest pain which becomes worse with inspiration or coughing and which may be relieved by sitting up and leaning forward.