Nursing School and the NCLEX ® Exam Foundations of Care Questions

A client scheduled for an operative procedure states to the nurse, "I am not sure if I should have this surgery." Which response should the nurse make to the client?

"Tell me what concerns you have about the surgery."

A client with heart disease says to the nurse, "I guess I'll never be able to eat ice cream again." How should the nurse respond to this client statement?

"You do not think you will be able to eat ice cream at all?" is a therapeutic response and rephrases the client's statement.

An antibiotic is diluted in 100 mL normal saline (NS) and is to be administered piggyback over 30 minutes. The drop factor is 10 drops (gtt)/mL. The nurse should set the flow rate at how many drops per minute? Fill-in-the-blank. Round to the nearest whole number.

100 mL * 10 drops (gtt)/mL / 30 mins= 33 gtt/minute

The nurse is calculating the client's fluid intake during a 12- hour period. The client consumed 4 oz of juice, 8 oz of coffee, and 6 oz of milk at breakfast. At lunchtime the client consumed 8 oz of iced tea and 6 oz of water. At dinnertime the client consumed 8 oz of coffee and 6 oz of lemonade. The client also consumed 4 oz of water at 10:00 am, at 2:00 pm, and again at 6:00 pm when receiving oral medications. At 8:00 am and 2:00 pm the client received an intravenous antibiotic diluted in 50 mL of normal saline. What would the nurse document as the client's total intake in milliliters? Fill-in-the-blank.

1840 mL

A primary health care provider has prescribed 25 mg of hydroxyzine hydrochloride intramuscularly. The nurse reads the label on the medication vial and administers how many milliliters to the client? Refer to figure. Fill-in-the-blank.

25 mg / 50mg * 1ml = 0.5ml

A primary health care provider's prescription reads morphine sulfate 7.5 mg intramuscularly stat. The medication ampule reads "morphine sulfate 10 mg per mL." The nurse should prepare how many milliliters to administer the correct dose? Fill-in-the-blank.

7.5 mg / 10 mg * 1ml = 0.75 mL

A clear liquid diet has been prescribed for a client. The nurse should offer which item to the client?

Apple juice , Remember that a clear liquid diet consists of foods that are relatively transparent.

The nurse instructs a client on a tyramine-restricted diet about foods that are acceptable to consume. The nurse should tell the client to consume which items in the diet? Select all that apply.

Apples Chicken Tomatoes

A 15-year-old seeks treatment for a sexually transmitted infection at a local clinic. With regard to informed consent, the nurse should perform which action?

Ask the client to sign the informed consent form. Parents normally must give informed consent for treatment of a minor. Some exceptions to this include the need for emergency treatment; when the consent of the minor is sufficient, such as for treatment of a sexually transmitted infection

The nurse creates a plan of care for a newly hospitalized client who reports difficulty sleeping. The nurse plans to implement which best intervention?

Ask the client what she or he does to prepare for sleep. Rationale: The best intervention is to ask what the client does to prepare for sleep. The nurse needs to assess habits that are beneficial to the client

The nurse instructs a client taking a potassium-sparing diuretic about foods high in potassium that need to be avoided. The nurse determines that the client "needs further instruction" if the client states that which food is high in potassium?

Celery , Celery is a vegetable that is low in potassium

The nurse provides instructions to a female client regarding the procedure for collecting a midstream urine sample. The nurse should tell the client to perform which action?

Cleanse the perineum from front to back. with the antiseptic wipes that are packaged with the specimen kit.

Oxygen by nasal cannula at 4 L/minute is prescribed for a hospitalized client. The nurse should perform which actions in the care of the client? Select all that apply.

Humidify the oxygen. Apply water-soluble lubricant to the nares. Instruct the client and family about the purpose of the oxygen.

The nurse is preparing to assist in performing a venipuncture to initiate continuous intravenous (IV) therapy with 0.9% normal saline solution. The nurse gathers the needed supplies and plans to perform which action before beginning the venipuncture?

Inspecting the 0.9% normal saline solution for particles or contamination. Rationale: All IV solutions should be free of particles or precipitates.

The nurse provides dietary instructions to a client diagnosed with iron-deficiency anemia. The nurse should tell the client to increase the intake of which food item?

Kidney beans , client with iron-deficiency anemia should increase intake of foods that are naturally high in iron, including kidney beans, soybeans, chickpeas, lima beans, cooked Swiss chard, red meat, liver

The nurse is teaching a client about a low-fat diet. The nurse should tell the client that it is acceptable to consume which food items? Select all that apply.

Lentil soup Watermelon Tomato soup Low-fat yogurt

The client has a platelet count of 60,000 mm3 (60 × 10 9 /L). The nurse should implement which measure in the care of this client?

Measuring the temperature using a temporal thermometer the nurse should measure the temperature using a temporal thermometer. Rectal thermometers are avoided because of the risk of bleeding, and oral thermometers are avoided if there is oral soreness or bleeding.

A client asks the nurse about the use of a complementary or alternative measure that will assist in promoting sleep. The nurse should make which suggestion?

Muscle relaxation techniques , A simple relaxation technique, such as muscle relaxation, can help reduce anxiety and promote sleep.

The nurse is caring for a client who is diagnosed with a terminal disease. The nurse should plan which appropriate interventions in the care of the client? Select all that apply.

Offer to contact the clergy to support the client's spiritual needs. Make referrals to other disciplines based on the client's stated needs. Plan to balance the client's need for assistance with that for independence. Ask the client about goals for the treatment plan and how she or he can best be assisted in achieving these goals.

A client's medication is available for injection in an ampule. Which action should the nurse take when drawing up this medication?

Place an alcohol wipe around the neck of the ampule before snapping it open.

The nurse is having a conversation with a client and responds to the client's statement by saying, "You say that your mother left you when you were 6 years old." The nurse is using which therapeutic communication technique?

Restating , the nurse repeats the main thought that the client expressed. indicates that the nurse is listening to the client. In this technique, the nurse validates, reinforces, or calls attention to something important that the client said

A client will be receiving long-term, continuous total parenteral nutrition (TPN) at home. The nurse should incorporate which priority client problem in the plan of care?

Social isolation , the client will be socially isolated from stimuli outside the home. Social isolation indicates that the client's ability to socialize with others will be limited as a result of the client's condition.

The nurse receives a telephone call from the hospital admission office and is told that a client with human immunodeficiency virus (HIV) will be admitted to the nursing unit. In planning infection control measures for the client, which is the best type of isolation precaution that the nurse should prepare?

Standard precautions ,

The nurse notes documentation in a client's medical record that the client is experiencing anuria. The nurse plans care based on which interpretation?

The client is unable to produce urine. Anuria is the term used to describe an inability to produce urine.

The nurse is caring for a client who has a fever and is diaphoretic. The nurse monitors the client's intake and output and expects to note which finding?

The client's output is decreased. diaphoretic (sweating)