Foundations exam 2 review questions

A nurse is assessing a client who has pneumonia. Which of the following findings should the nurse expect? Tachypnea Pulse deficit Hypothermia Bradycardia

Tachypnea

A nurse is caring for a client who is at risk for a pressure injury. Which of the following actions should the nurse take? Reposition the client every 4 hr. Massage the client's bony prominences. Provide the client with a high-calorie diet. Elevate the head of the client's bed 45°

Provide the client with a high-calorie diet.

A nurse is providing teaching to a client who has a prescription for amoxicillin 5 mL PO. How many teaspoons (tsp) should the nurse instruct the client to take? 2.5 tsp 5 tsp 0.5 tsp 1 tsp

1 tsp

A nurse in a pediatric unit is planning care for a group of clients. Which of the following clients should the nurse plan to use the Crying, Requires oxygen, Increased vital signs, Expression, Sleeplessness (CRIES) pain scale? A 3-year-old toddler who has a broken elbow A 4-year-old preschooler who had a tonsillectomy A 10-year-old client who had an appendectomy A 4-day-old infant who had a repair of a birth defect

A 4-day-old infant who had a repair of a birth defect

A nurse is preparing to administer penicillin IM to an adult client. Which of the following angles should the nurse use for injection into the client's ventrogluteal muscle? A. 45° B. 60° C. 75° D. 90°

D. 90°

A nurse is changing the bed linen for a client who is on contact precautions. Which of the following personal protective equipment should the nurse wear? N-95 respirator Goggles Face shield Gloves

Gloves

A nurse is teaching a class about routes of medication administration. The nurse should include that which of the following routes has the fastest rate of absorption? Topical Intravenous Intramuscular Enteral

Intravenous

A nurse is performing passive range of motion on a client who had a stroke. The nurse should identify that passive range of motion is performed to increase which of the following? Muscle mass Bone density Muscle strength Joint flexibility

Joint flexibility

A nurse is assessing a client who is a professional athlete. Which of the following findings should the nurse expect? Hypertension Decreased oxygen saturation Bradycardia Hypothermia

Bradycardia

A nurse is performing a pressure injury risk assessment for a client. Which of the following findings increase the client's risk of a pressure injury? BMI of 20 Peripheral neuropathy Immobility Hypoperfusion Prealbumin level of 16 mg/dL

BMI of 20 Peripheral neuropathy Immobility Hypoperfusion

A nurse is preparing to administer cefotaxime 1,000 mg IM to a client. How many grams (g) should the nurse plan to administer? A. 1g B. 0.1g C. 10g D. 100g

A. 1g

A nurse is assessing a client who reports acute pain at a level of 7 on a scale of 0 to 10. Which of the following findings should the nurse expect? A. Hypertension B. Decreased respiratory rate C. Bradycardia D. Hypoglycemia

D. Hypoglycemia

A nurse is assessing a client who is nonverbal for acute pain. Which of the following findings is a manifestation of pain? Constricted pupils Reduced respiratory rate Elevated blood pressure Decreased heart rate

Elevated blood pressure

A nurse is preparing to administer diphenhydramine 30 mg IM stat to a client who is having an allergic reaction. Available is diphenhydramine 50 mg/1 mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

0.6 ml

A nurse is preparing to administer 5% dextrose in 0.45% sodium chloride 1,000 mL IV to infuse over 12 hr. The nurse should set the IV pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

83 ml/hr

A nurse is preparing to reposition a client. Which of the following actions should the nurse take first? A. Raise the height of the client's bed. B. Tighten their abdominal muscles. C. Pivot their feet in the direction of the move. D. Place their feet in line with their shoulders.

A. Raise the height of the client's bed.

A nurse is assessing a client who received an opioid narcotic for incisional pain. Which of the following findings is the priority? A. Pain level B. Pulse oximetry C. Blood pressure D. Level of sedation

B. Pulse oximetry

A nurse is preparing to lift a heavy object. Which of the following actions by the nurse indicates an understanding of body mechanics? A. They bend at the hip when lifting. B. They stand close to the object being moved. C. They twist their spine when lifting. D. They keep their feet together when lifting an object.

B. They stand close to the object being moved.

A nurse is assessing a client who has a stage 2 pressure injury. Which of the following findings should the nurse expect? A. Full thickness skin loss with visible adipose tissue. B. Full thickness skin loss with visible bone C. Intact skin with localized erythema. D. Partial-thickness skin loss with red tissue in wound bed.

D. Partial-thickness skin loss with red tissue in wound bed.

A nurse is assessing a client who has a stage 1 pressure injury. Which of the following findings should the nurse expect? Intact skin with localized erythema Full thickness skin loss with visible adipose tissue. Full thickness skin loss with visible bone Partial-thickness skin loss with red tissue in wound bed

Intact skin with localized erythema

A nurse is caring for a client who has a Penrose drain. Which of the following actions should the nurse take? Clean the skin near the drain in a circular motion from the outside to the inside. Empty the drainage device when it is half full. Place a perforated gauze pad around the drain. Connect the drain to continuous low-pressure suction.

Place a perforated gauze pad around the drain.

A nurse administers the wrong medication to a client. Which of the following actions should the nurse take first? Check the client's vital signs. Document the client's condition in the electronic medical record. Notify the provider. Fill out an incident report.

Check the client's vital signs.

A nurse is teaching a newly licensed nurse about measuring body temperature in clients. The nurse should instruct to obtain an oral temperature in which of the following clients? SELECT ALL THAT APPLY A client who has hemorrhoids A client who had recent oral surgery A client who breaths through the mouth A client who is drinking ice water A client who has a coagulation disorder

A client who has hemorrhoids A client who has a coagulation disorder

A nurse is administering a powdered medication to a client. Which of the following actions should the nurse take first? Check the client for allergies. Determine the client's response to the medication. Mix the medication at the client's bedside. Document that the medication was administered.

Check the client for allergies.

A nurse is caring for a client who has a new diagnosis of Clostridium difficile and is placed on contact precautions. Which of the following actions should the nurse take? Remove the protective gown before leaving the client's room. Use an electronic thermometer to take the client's temperature. Remove protective gown before removing gloves. Shake bed linens before placing them in a linen bag.

Remove the protective gown before leaving the client's room.

A nurse is assessing a client for manifestations of pain. Which of the following findings is an objective indicator of pain? The client grimaces when they move. The client reports a burning sensation. The client rates their pain as an 8 on a scale of 0 to 10. The client states the pain is located on their abdomen.

The client grimaces when they move.

A nurse is assessing a client who has an infection. Which of the following findings is a manifestation of sepsis? SELECT ALL THAT APPLY Vomiting Hypoglycemia Hypertension Altered mental status Elevated WBC's count

Vomiting Elevated WBC's count Altered mental status

A nurse is teaching a class about converting household measurements into metric measurements. Which of the following information should the nurse include? 1 pint is equal to 960 mL 2 Tbsp is equal to 15 mL 1 tsp is equal to 10 mL 1 cup is equal to 240 mL

1 cup is equal to 240 mL

A nurse is preparing to administer 0.9% sodium chloride 1,000 mL IV to infuse over 8 hr. The nurse should set the IV pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

125 ml/hr

A nurse is caring for a client who is incontinent. Which of the following actions should the nurse take? Clean the client's skin with hot water. Restrict the client's fluid intake. Dry between folds in the client's skin. Apply baby powder to the client's skin.

Dry between folds in the client's skin.

A nurse is preparing to administer levothyroxine 0.175 mg PO once a day. The amount available is levothyroxine 88 mcg/tablet. How many tablets should the nurse administer per dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

2 tablets

A nurse is preparing to administer naproxen 500 mg PO BID for a client who has osteoarthritis. The amount available is naproxen 125 mg/5 mL oral suspension. How many mL should the nurse administer per dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

20 ml

A nurse is preparing to administer 1,000 mL of lactated Ringer's IV over 6 hr. The drop factor of the manual IV tubing is 10 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

28 gtt/min

A nurse is preparing to administer digoxin 12 mcg/kg/day PO to divide equally every 12 hr to a school-age child who weighs 66 lb. Available is digoxin elixir 0.05 mg/mL. How many mL should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

3.6 ml

A nurse is preparing to administer vancomycin 15 mg/kg/day divided equally every 12 hr. The client weighs 198 lb. How many mg should the nurse administer with each dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

675

A nurse is caring for a group of clients. Which of the following clients should the nurse identify is at highest risk for developing a pressure injury? A client who makes frequent slight changes in position and walks occasionally. A client who alert and responsive and eats 25% of each meal. A client who is receiving enteral feeding and can change position independently. A client who is unresponsive to verbal commands and changes position occasionally.

A client who is unresponsive to verbal commands and changes position occasionally.

A charge nurse is making client care assignments. Which of the following tasks should the nurse delegate to assistive personnel (AP)? (Select all that apply.) Bathe a client who had an amputation 2 days ago. Assist a client to ambulate using a gait belt. Review a low-sodium diet for a client who has hypertension. Explain oral hygiene to a client receiving chemotherapy. Feed a client who had a stroke 3 months ago.

Bathe a client who had an amputation 2 days ago. Assist a client to ambulate using a gait belt. Feed a client who had a stroke 3 months ago.

A nurse is caring for a client who has Clostridium difficile (C. difficile). Which of the following actions should the nurse take? Place the client in a room with negative pressure airflow. Apply a mask on the client when they are outside their room. Clean hands with soap and water after caring for the client. Wash hands for 10 seconds after caring for the client.

Clean hands with soap and water after caring for the client.

A nurse is preparing to change the linens on a client's bed. Which of the following actions should the nurse take? Place soiled linens on the floor while changing the client's bed. Hold soiled linen away from the nurse's clothing. Place the client's bed height in the lowest position. Shake soiled linens before placing them in a bag.

Hold soiled linen away from the nurse's clothing.

A nurse is observing a newly licensed nurse perform hand hygiene. Which of the following actions by the newly licensed nurse indicates an understanding of the procedure? Uses hot water to wash their hands Washes their hands for 10 seconds Holds their hands below the elbows while rinsing off soap Turns off the faucet with their hands

Holds their hands below the elbows while rinsing off soap

A nurse is assessing a client who is receiving continuous IV therapy through a peripheral IV. The catheter site is cool and taut, and there is IV fluid leaking. The nurse should identify that the client has manifestations of which of the following complications? Phlebitis Circulatory overload Infiltration Infection

Infiltration

A nurse is teaching a class about reducing the risk of medication errors. Which of the following information should the nurse include? Provide the nurse administering medications with an identifying vest. Wait to document medications given to clients until the end of a shift. Remove medications from automatic dispensing systems before they are reviewed by pharmacists. Prepare medications for multiple clients at the same time.

Provide the nurse administering medications with an identifying vest.

A nurse is assessing a client who has a heart rate of 56/min. Which of the following findings should the nurse expect? Report of dizziness History of cigarette smoking Hypoglycemia Temperature of 39° C (102.2° F).

Report of dizziness

A nurse is assessing a client who has opioid toxicity. Which of the following findings should the nurse expect? Temperature 38.2? C (100.8? F) Blood pressure 168/90 mm Hg Respiratory rate 10/min Heart rate 112/min

Respiratory rate 10/min

A nurse is preparing to perform hand hygiene with soap and water. Which of the following actions should the nurse plan to take? Use hot water to wash hands. Dry hands with a reusable towel. Wash hands for 10 seconds. Use a towel to turn off the water.

Use a towel to turn off the water.

A nurse is planning to perform perineal care for a female client. Which of the following actions should the nurse plan to take? Allow the client's perineum to air dry. Use soap and water to clean the client's perineum. Start at the client's rectum and clean to the client's perineum. Use the same section of washcloth for each area cleaned.

Use soap and water to clean the client's perineum.

A nurse is caring for a client. Nurses' Notes Day 1 0800: Client is alert and oriented Breath sounds are clear and present throughout. Denies tobacco use. Client lives in a 20-year-old, one-story house with their partner. Client reports they just returned from an 8-hr car trip. Client eats a high fiber diet and drinks 2,000 mL of fluid/day. Day 1,1000: 2.5 cm x 2.5 cm (1 in x 1 in) reddened area noted on client's left calf. Calf circumference: Left: 40 cm (15.8 in) Right: 38.1 cm (15 in) Day 2 0800: 3.8 cm x 3.8 cm (1.5 in x 1.5 in) reddened area noted on client's left calf. Calf circumference: Left: 42 cm (16.5 in) Right: 38.4 cm (15.1 in) Vital Signs Day 1 0800: Temperature 38° C (100.4° F) Blood pressure 106/55 mm Hg Heart rate 76/min Respiratory rate 18/min SaO2 95% on room air The client is at risk for developing __________ due to __________

the client is at risk for developing a pulmonary embolism due to possible deep vein thrombosis.

A nurse is preparing to administer levothyroxine 50 mcg PO to a client. How many milligrams (mg) should the nurse plan to administer? 50 mg 500 mg 0.05 mg 0.5 mg

0.05 mg

A nurse is preparing to move a client who is only partially able to assist up in bed. Which of the following methods should the nurse plan to use? One nurse lifting as the client pushes with his feet Two nurses lifting the client under the shoulders One nurse lifting the client's legs as the client uses a trapeze bar Two nurses using a friction-reducing device

Two nurses using a friction-reducing device

An infection control nurse is teaching a class about transmission of infectious agents. The nurse should include that which of the following diseases is transmitted via airborne transmission? Varicella Clostridium difficile Rubeola Staphylococcus aureus Tuberculosis

Varicella Rubeola Tuberculosis

A nurse is caring for a client. Laboratory Results 1400: Stool culture positive for Clostridium difficile (negative) Nurses' Notes 0800: Client is admitted with a 3-day history of abdominal cramps and diarrhea. Client reports 4 to 5 liquid stools/day. Client was taking amoxicillin/clavulanate for a respiratory tract infection, 500 mg PO q 12 hr for 10 days. Antibiotics completed 7 days ago. Abdomen soft, nondistended with hyperactive bowel sounds audible in 4 quadrants. Stool contains mucous and is foul-smelling. Stool sent for culture A nurse is caring for the client. Which of the following actions should the nurse take? Select all that apply. Wear a protective gown while caring for the client. Place the client in a private room. Wear an N-95 respirator while caring for the client. Place the client in a negative pressure room. Place a mask on the client when they leave their room.

Wear a protective gown while caring for the client. Place the client in a private room.

A nurse is teaching a newly licensed nurse about wearing medical masks. Which of the following statements should the nurse include? "Discard your mask after each use." "Position the mask on your face with the flexible metal piece at the bottom." "Remove your mask prior to removing your gloves." "Touch the front of your mask while wearing it."

"Discard your mask after each use."

A nurse is caring for a client who is on bedrest and is experiencing constipation. Which of the following interventions should the nurse implement? Encourage the client to drink cold fluids. Request a prescription for mineral oil for the client. Increase the client's fluid intake. Place the client on a low-fiber diet.

Increase the client's fluid intake.

A nurse is teaching a newly licensed nurse about pain. Which of the following is an example of nociceptive pain? Strained muscle Diabetic neuropathy Post-herpetic neuralgia Phantom limb pain

Strained muscle

A nurse is preparing to reposition a client towards the head of the bed. In which of the following positions should the nurse place the client before repositioning them to the head of the bed? Supine High-Fowler Lateral Prone

Supine

A nurse is assessing a client for manifestations of pain. Which of the following findings is a subjective indicator of pain? The client is restless. The client is grimacing. The client reports a burning sensation. The client's pupils are dilated.

The client reports a burning sensation.

A nurse is preparing to assist a client who can partially bear weight and is cooperative with transfer from the bed to a chair. Which of the following actions should the nurse take to maintain safety during the transfer? Enlist help from another staff member. Adjust the bed to an appropriate height. Use a powered standing-assist lift. Avoid movements that twist the spine.

Use a powered standing-assist lift.

A nurse is assisting an older adult client who sometimes loses her balance while walking. Which of the following devices should the nurse use when helping the client ambulate? A.Gait Belt B. Jacket harness C.Four-wheel walker D.Cane

A.Gait Belt

A nurse is preparing to administer gabapentin 900 mg PO once daily for a client who has neuropathic pain. The amount available is gabapentin 300 mg/capsule. How many capsules should the nurse administer per dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

3 capsules

A nurse is preparing to infuse a 250-mL unit of packed RBCs over 2 hr. The drop factor of the manual IV tubing is 15 gtts/mL. The nurse should adjust the flow rate to deliver how many drops per minute? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

31 gtt/min

A nurse is preparing to administer amoxicillin 320 mg PO every 12 hr to an infant. The amount available is amoxicillin suspension 400 mg/5 mL. How many mL should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

4 ml

A nurse working on an orthopedic unit is caring for four clients. Which of the following clients should the nurse identify as being at greatest risk for skin breakdown? An adolescent who has a cervical fracture and is in a halo brace A young adult who has a femur fracture and is in skeletal balanced suspension traction A middle adult who has a fractured radius and an arm cast An older adult who has a hip fracture and is in Buck's traction

An older adult who has a hip fracture and is in Buck's traction

A nurse is caring for a client who requires cold applications with an ice bag to reduce the swelling and pain of an ankle injury. Which of the following actions should the nurse take? Apply the bag for 30 min at a time. Reapply the bag 30 min after removing it. Allow room for some air inside the bag. Place the bag directly on the skin.

Apply the bag for 30 min at a time.

A nurse is assessing a client for orthostatic hypotension. Which of the following actions should the nurse take first? Place the client in a sitting position Check the blood pressure with the client in a supine position. Determine the client's blood pressure 1 min after each position change. Assist the client into a standing position.

Check the blood pressure with the client in a supine position.

A nurse is assessing a client who is experiencing complications due to immobility. Which of the following findings should the nurse expect? (Select all that apply.) Contractures of the extremities Polyuria Diarrhea Crackles in the lungs Pressure ulcers

Contractures of the extremities Crackles in the lungs Pressure ulcers

A nurse is preparing to administer cefadroxil oral suspension 15 mg/kg PO to a client who weighs 98 lb. Available is cefadroxil 250 mg/5 mL. Which of the following actions should the nurse take first? Calculate the dosage in milliliters. Round the amount to be administered to the nearest whole number. Calculate the dosage in milligrams. Convert the client's weight to kilograms.

Convert the client's weight to kilograms.

A nurse is assessing a client who has impaired mobility. The nurse should monitor the client for a pressure injury due to which of the following factors? Decreased circulation Increased collagen Increased muscle mass Decreased serum calcium

Decreased circulation

A nurse is planning care for a client who has dehydration and hypotension. Which of the following actions should the nurse plan to take? Increase the client's fluid intake. Instruct the client to perform the Valsalva maneuver. Encourage the client to use guided imagery to relax. Elevate the head of the client's bed.

Increase the client's fluid intake.

A nurse is observing a newly licensed nurse set up a sterile field. Which of the following actions by the newly licensed nurse indicates an understanding of the procedure? Prepares the sterile field 2 hr before it is needed Opens the first flap of the sterile package towards the nurse's body. Inspects the sterile package for holes before opening Places the sterile field against a wall in the client's room

Inspects the sterile package for holes before opening

A nurse is preparing to irrigate a wound for a client. Which of the following actions should the nurse plan to take? Chill the irrigant prior to the procedure. Flush the wound from the most contaminated area to the cleanest area. Hold the tip of the syringe at least 1.3 cm (0.5 in) above the wound while irrigating. Irrigate the wound until the solution that is draining is clear.

Irrigate the wound until the solution that is draining is clear.

A nurse is caring for a client who is immunocompromised following an allogenic hematopoietic stem cell transplant. The nurse should place the client on which of the following precautions? Airborne Droplet Protective Contact

Protective

A nurse is caring for a client who is experiencing impaired mobility. Medical History Client is admitted to the rehabilitation unit following a hip fracture 7 days ago. Client has limited mobility and requires full assistance to turn and transfer out of bed. Diagnostic Results Hct 48% (37% to 47%) Hgb 17 g/dL (12 g/dL to 16 g/dL) Urine specific gravity 1.040 (1.005 to 1.030) Nurses' Notes Day 1: Skin dry, skin turgor decreased Left calf circumference 31 cm (12.2 in) Right calf circumference 32 cm (13.8 in) Day 2: 2 cm (0.8 in) warm, reddened area noted on right calf Left calf circumference 31 cm (12.2 in) Right calf circumference 35 cm (13.8 in) The client is at risk for developing __________ and _________

The client is at risk for developing Deep vein thrombosis and Pulmonary embolism

A nurse is caring for a client who has postural hypotension. The nurse assists the client gradually from a lying down to standing position. The nurse should identify that which of the following findings indicates the intervention is effective? The client's systolic blood pressure decreases from 110 mm Hg to 105 mm Hg. The client reports dizziness. The client's heart increases from 100/min to 108/min. The client reports nausea.

The client's systolic blood pressure decreases from 110 mm Hg to 105 mm Hg.

A nurse is assessing a client who was brought to the emergency department with an ankle injury. Which of the following manifestations should the nurse identify as localized inflammation of the tissues? A. Full range of motion at the site of injury B. 3+ palpable pedal pulses below the affected injury site C. Localized warmth at the site of injury D. Sanguineous drainage at the site of injury

C. Localized warmth at the site of injury

A nurse is planning care for a client who has urinary incontinence. The nurse should plan to monitor the client for which of the following findings? Hypoglycemia Kidney stones Fluid volume overload Dermatitis

Dermatitis

A nurse on a medical-surgical unit is caring for a client. History and Physical Diabetes mellitus type 2 for 15 years Hypertension for 25 years Hyperlipidemia for 20 years History of smoking 40 packs per year Cerebrovascular accident (CVA) 5 days ago Nurses' Notes Day 1, Medical-Surgical Unit (5 days post-CVA): Client transferred from ICU via gurney, hand-off report received. Client asleep, respirations eupneic, heart rate regular. Abdomen soft, nondistended, active bowel sounds x4 quadrants. No edema noted, compression stockings present. Indwelling urinary catheter draining clear yellow urine. 14 French NG tube noted in right nares, clamped. Day 2, Medical-Surgical Unit (6 days post-CVA): Assessment completed. Client awakens for short periods of time, unable to speak, occasional moans noted. Client incontinent of stool, cleaned skin and barrier ointment applied. Skin intact without any areas of erythema. Client unable to reposition self. Occasional movement of left arm and leg noted, right side without movement. Physical therapists in to see client for morning exercises. NG tube noted in right nares, clamped. Provider Prescriptions Day 1, Medical-Surgical Unit (5 days post-CVA): Begin clopidogrel 75 mg via NG tube daily Diagnostic Results Day 1, Medical-Surgical Unit (5 days post-CVA): WBC count 6,900/mm3 (5,000 to 10,000/mm3) Hgb 16 g/dL (12 g/dL to 16 g/dL) Hct 41% (37% to 47%) Platelet count 310,000/mm3 (150,000 to 400,000/mm3) Day 2, Medical-Surgical Unit (6 days post-CVA): WBC count 7,200/mm3 (5,000 to 10,000/mm3) Hgb 16.5 g/dL (12 g/dL to 16 g/dL) Hct 42% (37% to 47%) Platelet count 330,000/mm3 (150,000 to 400,000/mm3) The client is at risk for developing _____________ and ________________

The client is at risk for developing Footdrop and pressure injury.

A nurse is reviewing laboratory values for a client. Which of the following findings indicates the presence of an infection? Creatine kinase 75 units/L Platelet count 200,000/mm3 Hgb 15 g/dL WBC count 22,000/mm3

WBC count 22,000/mm3