PN Fundamentals Online Practice 2023 B

A nurse in an emergency department (ED) is assisting in the care of a client. which of the following are s/s of malnourished

-Client is cachectic with flaccid muscle tone. -Skin is dry and scaly with bruises on extremities. -Pulse rate 118/min -Abdomen is distended -BMI 17

A nurse is assisting in the care of a client who has pancreatitis. Select the 3 tasks the nurse should delegate to an assistive personnel (AP)

-Document clients vital signs. -Measure intake and output -Transfer the client from wheelchair to the bed

A nurse is contributing to the plan of care for a client who is dying. Which of the following interventions should the nurse recommend to include the client's family in the plan of care? (Select all that apply.)

-Keep the family updated about the client's status -Encourage the family to comb the client's hair. -Tell the client's family what to expect as the client's death nears.

A nurse in an emergency department is caring for a client. The nurse should first _______, followed by_________

-Review the medications that may be causing the client's confusion. -Using alternative methods to keep the client safe.

A nurse is caring for a client who has a peripheral IV inserted for fluid replacement. A nurse is collecting data from the client. Which of the following actions should the nurse take? Select all that apply

-Stop the IV infusion -Elevate the client's left arm -Apply heat to the client's left hand

A nurse is caring for a group of clients in a long-term care facility. Which of the following actions should the nurse take to prevent health care-associated infections for these clients? (Select all that apply.)

-Wash hands after removing gloves -Use antimicrobial hand gel after refilling a client's water pitcher -Clean the stethoscope with an antimicrobial wipe after obtaining vital signs

A nurse is assisting with the care of a client who is receiving a unit of packed RBCs. Complete the following sentence by using the lists of options.

-an allergic reaction -itching

A nurse is caring for a client who is postoperative and is experiencing nausea and vomiting. The nurse should identify which of the following findings as indications that the client has fluid volume deficit?

-cool extremities -orthostatic hypotension -flat neck veins

A nurse is assisting in the care of a client who has a continuous enteral feeding. Select the 3 findings that require notification of the charge nurse.

-lung sounds -gastric residual -client cough

A nurse is admitting a client. The nurse is reviewing the client's medical record. Which of the following actions should the nurse take? Select all that apply

-place the client in droplet isolation precautions -apply oxygen at 2L/min via nasal cannula -request a prescription for an antipyretic medication -stay at least 0.9 (3 feet) away from the client when possible

A nurse is assisting in the admission of a client who reports experiencing a sore throat, productive cough, and fever for the past 3 days. What interventions?

-request a prescription for antibiotic -wear a mask with 1 m(3 feet) of the client -initiate droplet precautions -apply a mask on the client when the client leaves their room

A nurse is reinforcing dietary teaching with a client who has chronic kidney disease and requires a low-potassium diet. Which of the following food choices by the client demonstrates an understanding of the teaching?

1 cup of applesauce

A charge nurse smells smoke, enters the visitor restroom, and sees flames in the trash can. What is the sequence of actions that the nurse should take?

1. Evacuate clients from the area. 2. Pull the lever 3. Close the fire doors 4. Use fire extinguishers

A nurse is preparing to administer a medication to a preschooler and must convert the child's weight from pounds to kilograms. The child weights 30 lbs. How many kilos does the child weigh?

13.6 (divide 30/2.2)

A nurse is preparing to document information about a client's lower legs, which are swollen with 6 mm edema. Which of the following information should the nurse document?

3+ pitting edema

A nurse is contributing to the plan of care for four clients. For which of the following clients should the nurse indicate airborne precautions?

A client who has measles.

A nurse is collecting data from a client who is 2 days postoperative following a colostomy placement. Which of the following findings should the nurse report to the provider?

A purple-colored stoma

A nurse is caring for a client who is postoperative following a mastectomy. The client states, "I can barely look myself in the mirror." The nurse should identify that the client is experiencing which of the following?

Actual loss

A nurse is planning to perform wound irrigation for a client who has a large abdominal wound. Which of the following actions should the nurse plan to take?

Administer an analgesic 30 minutes before starting the procedure.

A nurse is caring for a postoperative client who is at risk for thrombus formation. Which of the following interventions should the nurse delegate to assistive personnel (AP)?

Apply thromboembolic stockings

A nurse is assisting with the plan of care for a client who has aphasia following a stroke. Which of the following interventions should the nurse use to assist the client with communication?

Ask the client close-ended questions.

A nurse is assisting with a plan of care for four clients. Which of the following tasks should the nurse assign to an AP?

Assist a client to get out of bed after a breathing treatment.

A nurse is reviewing the medical record of a female client who has heart failure. The nurse should identify which of the following laboratory results as an indication that the client has fluid volume excess?

BUN 8 mg/dL (10 to 20 mg/mL)

A nurse is caring for client who has prescription for a potassium supplement. The client tells the nurse that the pill is too large to swallow and refuses to take it. The nurse offers to break the pill into two smaller pieces. The nurse is demonstrating which of the following ethical principles?

Beneficence

A nurse is preparing to administer an enteral feeding to a client who has an NG tube in place. Which of the following methods should the nurse use to verify correct placement of the NG tube?

Check the pH of the gastric aspirate.

A nurse in a long-term care facility is collecting admission data from a client who uses a hearing aid. Which of the following actions should the nurse take?

Choose a private room for the interview.

A nurse is contributing to the plan of care for a client who has a prescription for elastic bandages to the lower extremities. Which of the following actions should the nurse recommend for the plan of care?

Compare the client's pedal pulses bilaterally every 4 hr.

A nurse is assisting with the admission of a client who has brought their medications to the facility. Which of the following actions should the nurse take?

Compare the medications the provider has prescribed with the client's medications from home.

A nurse is checking a client for a pulse deficit after detecting an irregular heart rate. Which of the following actions should the nurse take?

Count the client's radial and apical pulse simultaneously with another nurse.

A nurse is assisting with the admission of an older adult client to an acute care facility. The client states that they are afraid to go to sleep, fearing they will not wake up. Which of the following is a therapeutic response the nurse should make?

Describe your concerns about sleeping to me.

A nurse is contributing to the plan of care for a client who practices Islam. Which of the following questions should the nurse ask the client to clarify the client's religious preferences?

Do you consume pork products?

A nurse has delegated various client care tasks to the AP on the care team. Which of the following actions by the AP should the nurse identify as correct?

Donning a mask to measure the vital signs of a client who has pertussis.

A nurse is preparing to palpate a client's pulse. The nurse should recognize that which of the following pulses is located on the top of the client's foot?

Dorsalis pedis

A nurse working in a community clinic is talking with an older adult client who states that their life has no purpose. The nurse should identify that the client is in which of the following stages of Erikson's Theory of Psychosocial Development1/

Ego integrity vs despair

A nurse is contributing to the plan of care for a client who has a positive throat culture for streptococci. Which of the following interventions should the nurse recommend to be included in the plan of care?

Ensure that client wears a surgical mask during transportation throughout the facility.

A nurse is caring for a client who has chronic pain. The nurse recommends that the client concentrate on a memory of a pleasurable experience. Which of the following complementary therapies is the nurse suggesting?

Guided imagery

A nurse is reinforcing teaching about the use of crutches with a client who has a fractured right tibia and fibula. Which of the following statements by the client indicates an understanding of the teaching?

I will be sure to keep the crutch tips dry.

A nurse is repositioning a client who has quadriplegia and is in the supine position. Which of the following actions should the nurse take to prevent client musculoskeletal injury?

Internally rotate the client's hips by using a trochanter roll.

A nurse is assisting with the care of a client who has a prescription for IV therapy. The client tells the nurse that they have numerous allergies. Which of the following allergies should the nurse bring to the attention of the charge nurse prior to the initiation of the therapy?

Latex

A client who is scheduled to undergo surgery tells the nurse that they do not understand the procedure and are reconsidering their decision to have it. Which of the following actions should the nurse take?

Notify the charge nurse of the client's concern.

A nurse is contributing to the plan of care for a client who has a new prescription for a wrist restraint. Which of the following actions should the nurse include in the plan of care?

Pad bony prominences on the wrist.

A nurse is assisting with the admission of a client to a medical-surgical unit. Which of the following findings should the nurse identify as an indication that the client is malnourished?

Pallor with scaly skin

A nurse is planning to perform intermittent catheterization for a client who is unable to urinate. Which of the following actions should the nurse take first?

Perform a bladder scan

A nurse is caring for a client who reports difficulty sleeping at home. Which of the following recommendations should the nurse provide to promote a restful home sleep environment?

Perform muscle relaxation before bed.

A nurse is planning care for a group of clients. The nurse should expect to witness an informed consent for a client who will undergo which of the following procedures?

Performance of a paracentesis.

A nurse is providing care to four clients in an acute care setting. The nurse should identify that which of the following client statements presents an ethical dilemma?

Please don't tell the doctor, but I am taking my partner's oxycodone.

A nurse is collecting data from a client who has an NG tube set to low intermittent suction. Which of the following finding indicates hypomagnesemia?

Positive Chvostek's sign

A nurse is caring for a client who has a new diagnosis of cancer. Which of the following actions by the nurse maintains the client's confidentiality?

Providing client information to another nurse at the change of shift.

A nurse is an acute care setting is documenting postmortem care in a client's medical record. Which of the following information should the nurse include in the documentation?

Release of personal belongings form.

A nurse at a long-term care facility is caring for a client who is alert. Which of the following actions should the nurse take to protect the client's privacy?

Speak with the client about their condition after visitors have left.

A nurse is reinforcing teaching with a client about the use of crutches. Which of the following actions by the client indicates an understanding of the teaching?

The client advances the unaffected leg first while climbing stairs.

A nurse is caring for client who has just died and practiced the Islamic faith. Which of the following cultural practices should the nurse expect?

The client's face should be turned toward Mecca.

A nurse is caring for client who has chronic kidney disease. The nurse should identify that which of the following findings is the priority to report to the provider?

The client's output was 60 mL for the past 3 hr.

A nurse is caring for a client who has terminal illness and a family member asks why the client's mouth is continually open. Which of the following responses should the nurse take?

The reduced muscle tone relaxed the jaw muscles.

A nurse is reinforcing preoperative teaching with a client about how to turn, cough, and deep breathe. Which of the following statements by the client indicates an understanding of the teaching?

This can prevent pneumonia.

A nurse is reinforcing teaching with the partner of a client who is immobile. Which of the following instructions should the nurse give the partner about turning the client in bed?

Tighten your stomach muscles.

A nurse is preparing to obtain a client's vital signs. Which of the following actions should the nurse take when washing their hands?

Turn off the faucet with a clean paper towel after drying hands.

A nurse is reinforcing teaching about health promotion with a group of young adult clients. Which of the following information should the nurse include?

Young adults should receive a dental assessment every 6 months.

A nurse is assisting in the care of a client in a medical-surgical unit. Click to highlight the findings that indicate an improvement in the client's condition,

tissue, no odor, comfort level, decrease in wound size and tunneling.

A nurse is caring for a client and is concerned that the client might have a fecal impaction. Which of the following is the most important question for the nurse to ask?

water liquid stool