Dynamic Quiz Fundamentals Part 1

A nurse is collecting data for an adult client. What is the correct sequence of steps for data collection of the abdomen?

1. Inspection 2. Auscultation 3.Percussion 4.Palpation Rationale: The appropriate sequence for abdominal data collection is to inspect, auscultate, percuss, and 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:

A nurse is caring for a group of clients who are receiving oxygen therapy. Which of the following clients should the nurse plan to see first?

A client who has heart failure and is receiving 100% oxygen via a partial rebreather mask. Rationale: The nurse should frequently check the bag on a rebreather mask to ensure it inflates properly. If the bag is deflated, the client will rebreathe exhaled carbon dioxide instead of receiving the prescribed oxygen dose. Oxygen can cause toxicity and is highly combustible, and higher concentrations of oxygen increase the risk of client injury.

A nurse is preparing to administer a tuberculin skin test to a client. After performing hand hygiene, which of the following actions should the nurse take?

Circle the area of the injection with a pen Rationale: Circling the area using a pen ensures the nurse will examine the correct site when reading the test 48 to 72 hours later.

A nurse is caring for a client who requires a dressing change. Which of the following actions should the nurse take?

Clean the drain site from the center outward Rationale: The nurse should clean the drain site from the center outward to avoid introducing microorganisms from the periphery of the wound into the center of the wound.

A nurse is assisting with an admission interview for a client. Which of the following items of data should the nurse collect during the introduction phase of the interview?

Client's comfort and ability to participate in the interview. Rationale: Client's comfort and ability to participate in the interview.

A nurse is collecting data from a client who has fluid-volume excess. Which of the following findings should the nurse expect?

Crackles in the lung fields. Rationale: Manifestations of fluid-volume excess include crackles in the lungs, dependent edema, full neck veins when the client is upright, increased blood pressure, and sudden weight gain.

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

Data collection for the client Rationale: Before the nurse can formulate a plan of action, implement a nursing intervention, or notify the provider of a change in the client's status, he or she must first collect adequate data from the client. Assessing or collecting additional data will provide the nurse with the knowledge to make an appropriate decision.

A nurse is assisting a client who is eating at mealtime. Suddenly, the client grabs her neck with both hands and appears frightened. Which of the following actions should the nurse take first?

Determine whether the client is able to breathe Rationale: This client is demonstrating the universal choking gesture. If the client is unable to move air in our out, severe airway obstruction is present. The client will need emergency interventions to clear a partial obstruction, indicated by stridor or minimal airway passage. As long there is good air exchange and the client can cough and breathe spontaneously, the nurse should stay with the client and monitor her condition.

A nurse is caring for a client who has protein malnutrition. Which of the following foods should the nurse identify as a source of complete protein?

Eggs Rationale: Complete proteins contain all of the essential amino acids to support growth and homeostasis. Examples of complete proteins include eggs, meat, poultry, seafood, milk, yogurt, cheese, soybeans, and soybean products.

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 Rationale: The nurse should always directly face a client who has a hearing impairment and stand or sit at the same level to improve communication. Many clients who are hearing-impaired combine lip reading with their residual hearing when communicating.

A nurse is caring for a client who has a hearing impairment. Which of the following interventions should the nurse use when speaking with the client?

Face the client when speaking Rationale: The nurse should always directly face a client who has a hearing impairment and stand or sit at the same level to improve communication. Many clients who are hearing-impaired combine lip reading with their residual hearing when communicating.

A nurse is communicating with a group of clients about what to expect during the postoperative phase of a total hip arthroplasty. Which of the following elements of the communication process should the nurse identify as a sign of effective communication?

Feedback is provided.

A nurse in an urgent-care center is caring for a 15-year-old client whose symptoms suggest a sexually transmitted infection (STI). The client's parent is unavailable, but the client's grandmother accompanied the client to the clinic. Which of the following actions should the nurse take?

Have the adolescent sign the consent form Rationale: Unemancipated minors (i.e. those who do not live on their own, are not married, and are not in the military) can legally give informed consent for their diagnostic procedures and treatment in some situations. These situations include treatment for STIs and substance use disorders.

A nurse is assisting with planning care for a client who has anorexia and nausea due to cancer treatment. Which of the following interventions should the nurse suggest?

Limit drinking liquids when eating food Rational: Drinking beverages with food leads to early satiety and bloating, which results in the client consuming fewer calories.

A nurse is collecting data from a term newborn who is 8 hours old. Which of the following reflexes should the nurse identify as a preliminary indication that during gestation, the newborn developed the ability to hear?

Moro Rationale: The newborn extends both arms and legs outward and then draws them back inward in response to a loud noise such as a sudden clap. This is a general indication that the newborn heard the noise.

A nurse is collecting health history data from a client who is deaf and uses American Sign Language (ASL) to communicate. The nurse will be working with an ASL interpreter. Which of the following actions should the nurse perform when working with the interpreter?

Pace speech to allow time for interpreter to convey words.

A nurse is collecting data from a client. Which of the following actions should the nurse take to determine the client's tissue perfusion?

Perform a blanch test. Rationale: The blanch test is used to check capillary refill, which is an indicator of peripheral circulation and tissue perfusion.

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

Perform hand hygiene

A nurse is preparing to remove an NG tube for a client who had a partial colectomy. Which of the following actions should the nurse take?

Pinch the NG tube while removing the tube Rationale: The nurse should pinch the NG tube while removing it to decrease the risk of aspiration of any gastric contents.

A nurse has received a prescription for dextran to administer to a client. The nurse should recognize that dextran belongs to which of the following functional classifications?

Plasma volume expanders Rationale: Dextran and albumin are plasma volume expanders. They help correct hypovolemia in emergency situations such as after hemorrhage or burns.

A nurse is inserting an NG tube into a client who begins to cough and gag. Which of the following actions should the nurse take?

Pull the NG tube back slightly Rationale: The nurse should slightly pull back the NG tube and instruct the client to breathe slowly. Once the client relaxes, the nurse should gently advance the tube as the client swallows.

A nurse is preparing to administer a partial dose of a prefilled opioid analgesic parenterally to a client. Which of the following actions should the nurse plan to take?

Record the amount of medication wasted on the controlled substance inventory record Rationale: Two nurses should sign the controlled substance inventory record to document the amount of medication wasted.

A nurse is caring for a client who is hospitalized and has a new tracheostomy. Which of the following actions should the nurse take when performing tracheostomy care for the client?

Soak the inner cannula of the tracheostomy tube in normal saline Rationales: The inner cannula of the tracheostomy tube should be soaked in normal saline or a mixture of normal saline and hydrogen peroxide to loosen secretions.

A nurse is collecting data about a client's abdomen. Which of the following positions should the nurse tell the client to assume for this examination?

Supine Rationale: The nurse should tell the client to assume the supine position to promote relaxation of the abdominal muscles. Having the client bend the knees enhances relaxation of the stomach muscles.

A nurse is collecting data from a female client who reports abdominal pain. Further findings reveal 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

A nurse is reinforcing teaching with a group of clients about nutrition. Which of the following definitions of the recommended dietary allowance (RDA) should the nurse include in the teaching?

The RDA defines the level of nutrient intake that meets the needs of healthy people in various groups.

A hospice nurse is visiting with the family member of a client. The family member states that the client has insomnia almost nightly. Which of the following practices should the nurse identify as contributing to the client's insomnia?

The client watches television in bed during the day. Rationale: To promote sleep, the client should avoid watching television in bed. She should be in bed only for sleep or sexual activities.

A nurse is caring for an adult client who is grieving following the death of a loved one. Which of the following factors places the client at risk of developing complicated grief?

The death was sudden. Rationale: Complicated grief can occur when the death of a loved one is sudden and unexpected.

A nurse is administering an IM injection to a 5-month-old infant. Which of the following injection sites should the nurse use?

Vastus lateralis Rationale: The nurse should use the vastus lateralis site over the anterior thigh for IM injections for infants and children.

A nurse is collecting data about a client's respiratory system. Which of the following breath sounds should the nurse expect to hear over the periphery of the major lung fields?

Vesicular Rationale: Vesicular breath sounds are normal and described as low-pitched, soft sounds over the lungs' peripheral fields.

A nurse is collecting data from a client at admission. The client reports a latex allergy. Which of the following precautions should the nurse take when caring for this client?

Wrap IV tubing with tape Rationale: Although latex-free products are widely available, the nurse might encounter some products that contain latex such as IV tubing and monitoring cords and devices. The nurse should create a barrier between these items and the client (e.g. by wrapping them in non-latex tape or stockinette).

A nurse is caring for an older adult client who has an in-the-canal hearing aid. The client states that the hearing aid is making a whistling sound. The nurse should identify which of the following factors as the source of this sound?

Excessive wax in the ear canal Rationale: Factors that can make a hearing aid whistle include a poor seal with the ear mold, an ear infection, excessive wax in the ear canal, an improper fit, or a malfunction.

A nurse is collecting data on a client. The nurse should recognize that which of the following findings places the client at risk for impaired skin integrity?

Faint pedal pulses Rationale: Faint pedal pulses can indicate poor circulation and tissue perfusion that puts the client at risk for impaired skin integrity.

A nurse is preparing a sterile field for a procedure the provider will perform at the client's bedside. Which of the following actions should the nurse take?

Hold the sterile drape above the waist and away from the body Rationale: Contamination occurs when the nurse holds any object that will be part of the sterile field below the waist or allows the object to touch anything other than another sterile object.

A nurse is assisting a provider with performing thoracentesis to remove pleural fluid. How should the nurse position the client?

Leaning forward over a pillow Rationale: Leaning forward on a pillow and across an over-bed table is the optimal position for thoracentesis and chest-tube insertion. It widens the posterior intercostal spaces and makes it easier to access and drain the pleural fluid. Another position that facilitates thoracentesis is having the client upright in bed, turned to a side, and with the outermost arm extended upward.

A nurse is performing suctioning for a client who has a tracheostomy. Which of the following actions should the nurse take?

Pull back the suction catheter by 1 cm (0.5 in) if the client starts coughing Rationale: The nurse should pull back the suction catheter 1 cm (0.5 in) when the client starts to cough or if resistance is met. This will remove the catheter from the mucosal wall of the trachea prior to suctioning.

A nurse on a medical unit is caring for a client who has a seizure disorder. Which of the following items is the nurse's priority to keep near the client at all times?

Suction Equipment Rationales: Patient are at risk for aspirating .secretions.

A nurse is caring for a client who is scheduled to receive transcutaneous electrical nerve stimulation (TENS) for pain management. The client asks the nurse how a TENS unit helps relieve pain. Which of the following responses should the nurse make?

"It modulates the transmission of the pain impulse." Rationale: The nurse should inform the client that a TENS unit applies low-voltage electrical stimulation directly over a location of pain at an acupressure point. It modulates the transmission of the pain impulse and can also cause a release of endorphins to assist with pain relief.

A nurse is assisting with discharge teaching for a client who has type 2 diabetes mellitus. The client expresses concern about cooking an appropriate diet for her diabetes due to her cultural beliefs and preferences. Which of the following responses should the nurse provide?

"The dietitian will help you choose foods that meet both your cultural and health requirements." Rationale: This response shows respect for the client's food preferences and cultural needs by offering choices that meet her cultural and health requirements.

A nurse is preparing to administer eye drops to a client following surgery. Which of the following actions should the nurse take when instilling the eye drops?

Drop the eye medication into the lower conjunctival sac. Rationale: The nurse should drop the eye medication in the lower conjunctival sac to avoid placing the drops on the cornea and causing damage.

A nurse is caring for a client who has a gastric ulcer. The nurse should explain that prolonged exposure of the body to stress can also cause which of the following to occur?

Hyperglycemia Rationale: Stress causes an increase in the secretion of cortisol, which can cause hypertension and hyperglycemia.

A nurse in a provider's office is talking with an older adult client who reports having trouble sleeping. Which of the following statements should the nurse identify as a possible cause of the client's sleeping difficulties?

I often have cup of coffee with my dessert before going to bed. Rationale: Caffeine stimulates the CNS and is a diuretic which cause frequent urination.

A nurse is planning to reinforce teaching for a client who is learning to self-inject a medication subcutaneously. The nurse does not speak the client's language, so arrangements are made for a medical interpreter from the facility to assist. Which of the following actions should the nurse take when working with the interpreter and the client?

Make sure the client and the interpreter are culturally compatible Rationale: It is important that the interpreter and the client speak the same dialect. The nurse should also understand any cultural norms or practices that could make the interaction uncomfortable.

A nurse is caring for a client who requires the insertion of a nasogastric tube. Which of the following actions should the nurse take when preparing to insert the tube?

Measure the distance from the nose to the earlobe to the xiphoid Rationale: The nurse should use the tube to measure from the tip of the client's nose to the tip of the earlobe and then to the tip of the xiphoid and mark that as the length of the tube to insert.

A nurse is caring for a client who is receiving continuous enteral feedings. Which of the following actions should the nurse take?

Monitor the client's blood glucose level Rationale: The nurse should monitor the client's capillary blood glucose level due to the risk of hyperglycemia while receiving enteral nutrition. The glucose level in the enteral nutrition solution places the client at risk for this complication.

A nurse is assisting with planning a community presentation for parents. When suggesting a discussion of controlling impulses and cooperating with others, the nurse should plan to relate it to Erikson's developmental task for which of the following age groups?

Preschoolers Rationale: Helping children control impulses and cooperate with others relates to Erikson's developmental task for preschoolers, which is initiative vs guilt. Altered development during this stage can result from harsh punishment and excessive limits on behavior, leading to guilt and frustration.

A nurse is contributing to the planning of an in-service session about nutrition. Which of the following pieces of information should the nurse recommend for the teaching?

Protein serves as an energy source when other sources are inadequate. Rationale: Protein serves as an energy source when other sources are inadequate.

A nurse delegates the collection of a client's temperature to an assistive personnel (AP). The nurse notes in the documentation that the AP obtained the client's axillary temperature; however, the nurse wanted an oral temperature. The nurse should identify that which of the following rights of delegation should have prevented this situation from occurring?

Right communication Rationale: The situation could have been avoided if the right communication was given by the nurse to the AP. The right communication entails providing clear, concise instructions regarding the task, including the objective, limits, and expectations.

A nurse is reviewing the laboratory data of a client who has a fever and watery diarrhea. Which of the following results should the nurse report to the provider?

Sodium 150 mEq/L Rationale: A sodium level of 150 mEq/L is greater than the expected reference range of 135 to 145 mEq/L. This client is at risk for dehydration due to diarrhea. Hypernatremia is a manifestation of dehydration, and the nurse should report this finding to the provider.

A nurse is contributing to the plan of care for a client who has a wound infection following abdominal surgery. To promote healing and fight infection, which of the following vitamins and/or minerals should the nurse plan to increase in the client's diet?

Vitamin C and zinc Rationale: The client's body needs both vitamin C and zinc to help fight a wound infection. The client should receive a multivitamin plus a mineral supplement. In addition, vitamin E supplements also are needed to promote skin and wound healing.