PassPoint - Nursing Fundamentals 1

The nurse is assessing a client's respiratory status. Which assessment data indicate a problem?

correct response28 breaths/min and audible Twenty-eight breaths are outside the normal range of 14 to 20 breaths/min. Breathing should be without effort or adventitious sounds. Based on these abnormal assessment findings, this client may be experiencing respiratory distress. The rest of the choices are all within normal parameters of respiratory status.

A client's arterial blood gas values are shown. The nurse should develop a care plan based on the fact the client is experiencing which clinical situation?

Correct response: metabolic acidosis The pH of 7.24 indicates that the client is acidotic. The carbon dioxide level is normal, but the HCO3- level is decreased. These findings indicate that the client is in metabolic acidosis.

A client whose child has died is withdrawn, has flat affect, makes minimal eye contact, and states, "I can't live without my child." What is the most appropriate response by the nurse?

correct response: "I would like to sit with you and talk about your child." This choice is the focused therapeutic response that would generate client-focused discussion. Calling someone else is not client focused and nursing intervention based. Stating that this is a normal response is nontherapeutic, and calling the health care provider is incorrect because the it is within the nurse's scope of practice to resolve this issue.

A nurse is giving a bed bath to a terminally ill client. The client tells the nurse that the client has great respect and faith in a particular spiritual leader. Which is the best response by the nurse?

correct response: "It sounds like that offers you a sense of security." Spiritual or religious beliefs give meaning to life, illness, other crises, and death; contribute a sense of security for present and future; guide daily living habits; drive acceptance or rejection of other people; furnish psychosocial support within a group of like-minded people; provide strength in meeting life's crises; and give healing strength and support. The nurse can respond to the client by validating the client's sense of security. It is not therapeutic for the nurse to judge whether a spiritual belief is good or bad. It is false hope to tell the client that people with strong beliefs have better outcomes. It is not the nurse's place to tell the client to think about the client's spiritual leader in times of doubt.

A client is prescribed heparin 6,000 units subcutaneously every 12 hours for deep vein thrombosis prophylaxis. The pharmacy dispenses a vial containing 10,000 units/1 ml. How many milliliter(s) of heparin would the nurse administer? Record your answer using one decimal place. (For example: 6.2)

correct response: 0.6 The dose dispensed by the pharmacy is 10,000 units/1 ml, and the desired dose is 6,000 units. The nurse should use these equations to determine the amount of heparin to administer: 10,000 units/1 ml = 6,000 units/1 ml; 10,000X = 6,000 ml; 6,000 ml/10,000 ml = 0.6 ml.

A palliative care nurse is caring for a client with end stage pancreatic cancer who is reporting severe pain. The healthcare provider orders morphine sulfate 4mg IV stat followed by morphine sulfate 2mg IV q 1h prn pain. The drug available in a multidose ampule of 2mg/mL. How many mL does the nurse administer for the initial dose? Record your answer as a whole number.

correct response: 2 The ANA Code of Ethics for Nurses provision 3 states that the nurse promotes, advocates for, and strives to protect the health, safety, and rights of the patient. This is crucial during medicating a palliative client. The initial dose ordered is 4 mg. The dose available is 2 mg. The quantity is 1mL. It is a multiple dose vial. 4mg/2 mg x 1 mL = 2 mL using the (dose ordered/units) x quantity method.

A client is using patient-controlled analgesia (PCA) to manage postoperative pain. What should the nurse do when assisting the client with the PCA?

correct response: Document the client's response to pain medication. It is essential that the nurse document the client's response to pain medication on a routine, systematic basis. Reassuring the client that pain will be relieved is often not realistic. A client who continually presses the PCA button may not be getting adequate pain relief, but through careful assessment and documentation, the effectiveness of pain relief interventions can be evaluated and modified. Pain medication is not titrated until the client is free from pain but rather until an acceptable level of pain management is reached.

Nurses are aware that variety and diversity occur both within and across groups. Which factor leads to cultural benefits as a result of diversity?

correct response: Equal opportunity exists for various cultural perspectives. Culture benefits from diversity only when the playing field is level and when equal opportunity exists for various cultural perspectives. When a dominant culture overpowers the outward public expressions of other cultures, conflicts and suppression may occur in people of differing cultural orientations. Such situations can be highly stressful.

The nurse observes a new parent give an oral medication to a 4-month-old infant. The parent instills the medication directly in the back of the infant's throat. Which choice is the nurse's best action?

correct response: Instruct the parent to instill a small amount of the medication inside the baby's cheek. The parent's technique of instilling the medication in the back of the throat is not correct and could cause the infant to choke. The nurse should instruct the parent to instill a small amount at a time inside the infant's cheek. The parent should hold an infant in the bottle-feeding position when administering an oral medication by placing the child's inner arm behind the back, supporting the head in the crook of the elbow, and holding the child's free hand with the hand of the supporting arm. Propping a 4-month-old infant is not appropriate. The infant cannot sit unsupported even in a seated position. Administering medication to an infant lying flat could cause choking and aspiration.

Which information should the nurse include when teaching the family and a client who was prescribed benztropine, 1 mg PO twice daily, about the drug therapy?

correct response: The client should not discontinue taking the drug abruptly. The nurse should teach the client and family the importance of not discontinuing benztropine abruptly. Rather, the drug should be tapered slowly over a 1-week period. Benztropine should not be used with over-the-counter cough and cold preparations because of the risk of an additive anticholinergic effect. Antacids delay the absorption of benztropine, and alcohol in combination with benztropine causes an increase in central nervous system depression; concomitant use should be avoided.

Which type of surgery is most likely to cause the client to experience postoperative nausea and vomiting?

correct response: abdominal hysterectomy Although any client may experience nausea and vomiting secondary to anesthetics or postoperative analgesics, the client who has had manipulation of the abdominal organs is more prone to postoperative nausea and vomiting than the client who has had a procedure such as a total joint replacement, open heart surgery, or a mastectomy.

Which documentation would indicate nursing actions were effective in reducing breathing problems for a client? Select all that apply.

correct response: anxiety decreased, oxygen saturation levels at 94%, nonproductive cough, respirations at 22 breaths/min lung sounds clear bilaterally with non-labored respirations noted A decrease in anxiety with an increase in oxygen saturation and clear lung sounds with non-labored respirations show documentation that breathing has improved. The other answers indicate abnormal data of the respiratory status.

The nurse uses which part of the SBAR acronym when stating, "The client is dry."

correct response: assessment SBAR stands for Situation, Background, Assessment, and Recommendation. It is a proven standardized method of communication between members of the health care team and a client's condition. SBAR is used as a standardized method of hand-off communication. A hand-off is a transfer of responsibility from one caregiver to another caregiver. The information communicated during a hand-off must be accurate, with minimal interruptions, in order to meet client safety needs.

A client has been diagnosed with septic shock. The nurse would anticipate implementing which order?

correct response: blood chemistry of serum lactate Measuring blood chemistry of lactate can indicate sepsis. Lactate is a byproduct of ineffective cellular metabolism. The other answers are incorrect because dextrose is not a fluid volume expander and the rate is too low. Vitals would be monitored more frequently in sepsis. The other lab values are liver function tests.

The nurse manager is preparing to meet with several registered nurses (RNs) in the department to address practice issues. Which behavior by an RN will the nurse manager address as a violation of the RN's "duty to care"?

correct response: declined assignment to care for a client with dementia who was incontinent of stool The duty to care in nursing refers to the ethical obligation that nurses have to their clients. Nurses can refuse to care for clients on several grounds such as moral conflict, feeling unsafe, or lacking the skills needed to safely deliver care. The nurse cannot refuse care based on the client's health concerns. Falsifying medical records is a breach of the ethical duty to be truthful and accurate in communications. Sharing information on social media breaches the nurse's ethical duty to protect client confidentiality. Making a medication error is a question of competence related to this skill rather and is not related to the duty to care.

A nurse must assess skin turgor in an older adult client. What would the nurse keep in mind when assessing this client?

correct response: inelastic skin turgor is a normal part of aging Inelastic skin turgor is a normal part of aging. Dehydration — not overhydration — causes inelastic skin with tenting. Overhydration — not dehydration — causes the skin to appear edematous and spongy. Normal skin turgor is dry and firm.

The nurse is caring for a client with asthma. The nurse should conduct a focused assessment to detect:

correct response: inspiratory and expiratory wheezing. The hallmark signs of asthma are chest tightness, audible wheezing, and coughing. Inspiratory and expiratory wheezing is the result of bronchoconstriction. Even between exacerbations there may be some soft wheezing, so a finding of normal breath sounds would be expected in the absence of asthma. The expected finding is decreased forced expiratory volume (forced expiratory flow [FEF] is the flow [or speed] of air coming out of the lung during the middle portion of a forced expiration) due to bronchial constriction. Morning headaches are found in more advanced cases of COPD and signal nocturnal hypercapnia or hypoxemia.

A client has just been transferred to the postanesthesia recovery room following a laparotomy. The nurse has completed assessing vital signs. What other important initial assessments would the nurse make?

correct response: level of consciousness, pain level, and wound dressing Postoperatively, vital signs are taken to ensure that vital systems are returning to normal after anesthesia. It is also important to check the level of consciousness, particularly postanesthesia and postanalgesia. Pain levels need to be monitored. Dressings need to be checked to detect abnormal increase in bleeding. The nurse would not check metabolic rate and reflexes, emotional response, or social support systems as an initial assessment after surgery.

The nurse is admitting a female adolescent for a wound debridement post-trauma injury to an ambulatory care unit. What diagnostic results will the nurse report to the surgeon prior to sending the client to the operating room? Select all that apply.

correct response: positive pregnancy test chest radiography with atelectasis The nurse needs inform the surgeon of the positive pregnancy test and the chest radiography with atelectasis because they may impact the anesthesia and surgical outcome. Normal blood glucose is 70-99 mg/dl. The platelet count normal is 150-450 103/µL and the white blood cell count is normal 3.5-10.5 103/µL.

A client who has been scheduled to have a choledocholithotomy expresses anxiety about having surgery. Which nursing intervention would be the most appropriate to achieve the outcome of anxiety reduction?

correct response: providing the client with information about what to expect postoperatively Providing information can help to answer the client's questions and decrease anxiety. Fear of the unknown can increase anxiety. Telling the client not to be afraid, that the procedure is common, or to follow the HCP's prescriptions will not necessarily decrease anxiety.