Foundations Proctored Exam Pt #2

C. Confirm unresponsiveness

103. A charge nurse is teaching adult cardiopulmonary resuscitation (CPR) to a group of newly licensed nurses. Which of the following actions should the charge nurse teach as the first response in CPR? A. Call for assistance B. Begin chest compressions C. Confirm unresponsiveness D. Give rescue breaths rescue breaths.

D. "Would you like to talk about how you feel?

70. A nurse is caring for a client who has cancer and refuses visitors because of his debilitated physical appearance. Which of the following comments should the nurse make? A. "You look just fine to me" B. "Nobody expects you to look beautiful in the hospital" C. "I understand how you feel. I would feel the same way." D. "Would you like to talk about how you feel?"

B. "I can't sleep well because whenever I move in my sleep, the pain wakes me up."

54 . A nurse is caring for a client who has injuries resulting from a motor-vehicle crash. Which of the following client statements should the nurse address first? A. "I'm afraid this injury will cause me to lose my job." B. "I can't sleep well because whenever I move in my sleep, the pain wakes me up." C. "I don't know what I will do if my car isn't safe or even drivable after the crash." D. "I wonder how I am going to be able to take care of my family."

D. Young adulthood

69. A nurse is evaluating the development of a group of clients. According to Erikson, the developmental task of intimacy vs. isolation occurs during which of the following stages of development? A. Middle adulthood B. Adolescence . C. Childhood D. Young adulthood

D. Observe the client closely

100. A nurse in a long-term care facility is in the dining room while residents are eating lunch. One resident begins to choke and is coughing strongly. Which of the following actions should the nurse take? A. Assist the client to the floor B. Perform an abdominal pain C. Open the airway with a head-chin tilt D. Observe the client closely

D. Ask the adolescent to sign the consent form

101. 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? A. Explain that the treatment can wait until the parent is available. B. Inform the grandmother that she may give consent for the treatment C. Invoke the principle of implied consent and prepare the client for treatment D. Ask the adolescent to sign the consent form

A. Assessment

102. 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? A. Assessment B. Plan of Care C. Nursing interventions performed D. Evaluation of progress

C. Dorsalis Pedis

64. A nurse is assessing a client's pulses of the lower extremities. The nurse should identify which of the following as the location of the most distal pulse? A. Popliteal B. Posterior Tibial C. Dorsalis Pedis D. Femoral

A. Scoliosis

65. A nurse is screening a client who has an S-shaped spinal column with unequal shoulder heights. The nurse should identify these findings as manifestations of which of the following abnormalities? A. Scoliosis B. Lordosis C. Torticollis D. Kyphosis

B. "I'll wash my hands before I remove the old dressing and again before putting on the new one."

55. A nurse is preparing a client for discharge and providing instructions about performing dressing changes at home. Which of the following statements should the nurse identify as an indication that the client understands medical asepsis? A. "I'll wrap the old dressing in a paper bag and put it in the trash." B. "I'll wash my hands before I remove the old dressing and again before putting on the new one." C. "I'll need to take a pain pill 30 minutes before I change the dressing." D. "I'll wear sterile gloves when I apply the new dressing."

C. Place the wheelchair at a 45-degree angle to the bed. ion required.

57. A nurse on a rehabilitation unit is preparing to transfer a client who is unable to walk from a bed to a wheelchair. Which of the following techniques should the nurse use? A. Stand toward the client's stronger side. B. Instruct the client to lean backward from the hips. C. Place the wheelchair at a 45-degree angle to the bed. ion required. D. Assume a narrow stance with the feet 15 cm (6 in) apart.

D. "Using a cuff that is too small will result in an inaccurately high reading."

66. A nurse observes an assistive personnel (AP) preparing to obtain blood pressure with a regular-sized cuff for a client who is obese. Which of the following explanations should the nurse give the AP? A. "The reading will be inaudible if the cuff is too small for the client." B. "The width of the cuff bladder should be 75% of the circumference of the client's arm." C. "As long as the cuff will circle the arm, the reading will be accurate." D. "Using a cuff that is too small will result in an inaccurately high reading."

A. Vitamin C and zinc

76 . A nurse is planning care for a client who has a wound infection following abdominal surgery. To promote healing and fight infection, which of the following vitamins and minerals should the nurse plan to increase in the client's diet? A. Vitamin C and zinc B. Vitamin D C. Vitamin K and iron D. Calcium

660 mL

79. A nurse is monitoring a client's fluid intake. For breakfast, the client consumed 8 oz of milk, 10 oz of water, 4 oz of flavored gelatin, 1 scrambled egg, 1 crisp piece of bacon, and 2 biscuits with jelly. How many mL should the nurse record as the client's fluid intake? (Nearest whole number)

D. Clean the drain site from the center outward

93. A nurse is caring for a client who requires a dressing change. Which of the following actions should the nurse take? A. Clean the incision from bottom to top B. Apply sterile gloves prior to opening dressing packages C. Remove the tape by pulling away from the wound D. Clean the drain site from the center outward

C. Determine whether the client is able to breathe

95. 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? A. Place an oxygen mask on the client B. Check the client's pulses C. Determine whether the client is able to breathe D. Wrap arms around the client from behind

A. "There are times I should use soap and water rather than an alcohol-based rub to clean my hands."

56. A nurse is teaching an assistive personnel (AP) about proper hand hygiene. Which of the following statements by the AP indicates an understanding of the teaching? A. "There are times I should use soap and water rather than an alcohol-based rub to clean my hands." B. "I will use cold water when I wash my hands to protect my skin from becoming dry." C. "I will apply friction for at least 10 seconds while washing my hands." D. "After washing my hands, I will dry them from the elbows down."

D. Perform hand hygiene

58. A nurse is preparing to provide tracheostomy care for a client. Which of the following actions should the nurse perform first? A. Open all sterile supplies and solutions. B. Stabilize the tracheostomy tube. C. Put on sterile gloves D. Perform hand hygiene

D. Granulation tissue fills the wound during healing

86. A nurse is providing teaching to a group of unit nurses about wound healing by secondary intention. Which of the following pieces of information should the nurse include in the teaching? A. The wound edges are well-approximated B. The wound is closed at a later date C. A skin graft is placed over the wound bed D. Granulation tissue fills the wound during healing

C. Taut skin around the IV catheter site that is cool to the touch

87. A nurse is caring for a client who is receiving IV fluid replacement. Which of the following findings should the nurse identify as infiltration of the IV infusion site? A. Redness at the IV catheter entry site B. Palpable cord along the vein used for the infusion C. Taut skin around the IV catheter site that is cool to the touch D. Bleeding at the IV insertion site

B. Educating clients about the recommended immunization schedule for adults

67. A home health nurse is planning to provide health promotion activities for a group of clients in the community. Which of the following activities is an example of primary prevention? A. Teaching clients to perform self-examinations of breasts and testicles B. Educating clients about the recommended immunization schedule for adults C. Teaching clients who have type 1 diabetes mellitus about care of the feet D. Recommending that clients over the age of 50 have a fecal occult blood test annually

A. Gown B. Gloves

59. A nurse is preparing to change the bed linens of a client who has AIDS and is incontinent of stool. Which of the following personal protective equipment (PPE) items should the nurse don prior to providing client care? (SATA) A. Gown B. Gloves C. Mask D. Hair cover E. Goggles

C. Don gloves when entering the room and use hand sanitizer when exiting

60. A nurse is caring for a client who has a methicillin-resistant Staphylococcus aureus (MRSA) infection. A dietary assistant asks the nurse what precautions are necessary for entering the client's room with the lunch tray. Which of the following instructions should the nurse give to the dietary assistant? A. Don a gown before entering the room and remove it before exiting B. Wear a mask while in the client's room C. Don gloves when entering the room and use hand sanitizer when exiting D. Take no special precautions unless engaging in direct contact with the client

B. Obtaining cotton balls for tracheostomy care

61. A charge nurse is observing a newly licensed nurse perform tracheostomy care for a client. Which of the following actions by the newly licensed nurse requires interventions? A. Obtaining hydrogen peroxide for tracheostomy care B. Obtaining cotton balls for tracheostomy care C. Obtaining sterile gloves for tracheostomy care D. Obtaining a sterile brush for tracheostomy care

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

62. A nurse is providing nutritional teaching to a group of clients. Which of the following definitions for the recommended dietary allowance (RDA) should the nurse include in the teaching? A. The RDA is a comprehensive term that includes various standards and scales. B. The RDA defines the level of nutrient intake that meets the needs of healthy people in various groups. C. The RDA defines the levels of nutrients that should not be exceeded to prevent adverse health effects. D. The RDA is the daily percentage of energy intake values for fat, carbohydrate, and protein.

D. Grains

63. A nurse is reviewing a client's 24 hr dietary recall. The client reports eating a slice of toasted white bread with butter, a banana, a glass of milk, and a cup of coffee for breakfast; grilled chicken, a baked potato, and a glass of milk for lunch; an apple and cheddar cheese for a snack; and 2 servings of chicken, 2 cups of steamed broccoli, and a glass of milk for dinner. This client's diet is deficient in which of the following food groups? A. Dairy B. Vegetables C. Fruits . D. Grains

B. Ask the client to identify the specific food allergies

68. A nurse is performing an admission assessment for a client who has asthma and reports several food allergies. Which of the following actions should the nurse take first? A. Document the client's food allergies in the medical record B. Ask the client to identify the specific food allergies C. Monitor the client for indications of anaphylaxis D. Have epinephrine available for administration

C. "I keep having nightmares about my upcoming surgery."

71. A nurse in an oncology clinic is assessing a client who is undergoing treatment for ovarian cancer. Which of the following statements by the client indicates she is experiencing psychological distress? A. "My parents are retired, and they have come to help with our children." B. "I am going to ask my husband to go to counseling with me." C. "I keep having nightmares about my upcoming surgery." D. "My girlfriends bought me a nice wig."

C. "Let's set up a meeting time with the doctor to discuss your options for home care."

72. A nurse is caring for a client who has a terminal illness. The family wants to care for the client at home. Which of the following statements indicates that the nurse understands family centered care? A. "Social services can contact various community resources that will be helpful." B. "I will review the care plan to make the necessary changes." C. "Let's set up a meeting time with the doctor to discuss your options for home care." D. "I will make a list of things we need to do before discharge."

B. Accompany the client back to his room

73. A nurse is caring for a group of clients in a long-term care facility. One of the clients is walking along the hallway and bumping into walls and does not respond to his name. Which of the following actions should the nurse take first? A. Offer the client a nutritious snack B. Accompany the client back to his room C. Reorient the client to his surroundings D. Administer a PRN antianxiety medication first.

B. Allow the client to maintain the same bedtime routine as at home

74. A nurse on a medical unit is caring for a client who has difficulty sleeping. Which of the following actions should the nurse take to promote the client's ability to fall asleep? A. Encourage the client to ambulate in the hallway just before bedtime B. Allow the client to maintain the same bedtime routine as at home C. Keep the room temperature warm D. Offer the client a cup of hot chocolate before bedtime

A. Encourage the client to listen to soft music

75. A nurse is caring for a client who has cancer and is experiencing pain. The nurse should implement which of the following interventions to assist the client with pain relief? A. Encourage the client to listen to soft music B. Instruct the client to practice tai chi C. Place a jasmine-scented air freshener in the client's room D. Offer the client ginger tea

B. Fill the bag 2/3 full with ice

77. A nurse is applying an ice bag to the ankle of a client following a sports injury. Which of the following actions should the nurse take? A. Leave the bag in place for 45 mins B. Fill the bag 2/3 full with ice C. Place the ice bag uncovered on the client's ankle ankle to prevent injury to the client's skin. D. Tell the client numbness is expected when the ice bag is in place

A. Ask why the client is refusing the pain medication

78. A nurse is caring for a client who has a terminal illness. The client is restless and reports severe pain but refuses the prescribed opioid pain medication. Which of the following actions should the nurse take first? A. Ask why the client is refusing the pain medication B. Administer a PRN antianxiety medication C. Help the client change positions D. Offer the client a heat or cold pack to place on painful areas

B. The client holds the hand with the palm down

80. A nurse is teaching ROM exercises to a client who has osteoarthritis. Which of the following client positions demonstrates an understanding of supination of the hand? A. The client holds the hand with the palm up B. The client holds the hand with the palm down C. The client points the fingers toward the floor D. The client points the fingers toward the ceiling

A. Hold the medication bottle with the label against the palm of the hand when pouring

82. A nurse is preparing to administer liquid medication from a bottle to a client. Which of the following actions should the nurse take first? A. Hold the medication bottle with the label against the palm of the hand when pouring B. Place the cap with the inside facing down on a hard surface C. Fill the cup until the medication is even with the edge of the dosage scale D. Pour any excess liquid back into the bottle after measuring

D. "I can still use my transcutaneous electrical nerve stimulation unit while I'm pushing the PCA button."

83. A nurse is teaching a client who is using a patient controlled analgesia (PCA) pump to deliver morphine for pain management. Which of the following statements should the nurse identify as an indication that the client understands the instructions? A. "I'll limit pushing the button, so I don't get an overdose." safety feature prevents analgesic overdosing. B. "If I push the button and still have pain after 2 mins, I'll push it again." C. "I'll ask my niece to push the button when I am sleeping." D. "I can still use my transcutaneous electrical nerve stimulation unit while I'm pushing the PCA button."

B. Verify the initial X-Ray examination C. Measure the length of the exposed tube D. Determine the pH of aspirated fluid

84. A nurse is caring for a semiconscious client who had a small-bore NG tube placed yesterday for the administration of enteral feeding. Which of the following methods should the nurse use to verify correct tube placement? (SATA) A. Auscultate injected air B. Verify the initial X-Ray examination C. Measure the length of the exposed tube D. Determine the pH of aspirated fluid

A. coat the tip of the tube with a water-soluble lubricant B. Ask the client to swallow water while the tube enters her throat D. Tell the client to tilt her head backward as insertion begins

85. A nurse is preparing to insert an NG tube for a client. Which of the following actions will help facilitate the insertion of the tube? (SATA) A. coat the tip of the tube with a water-soluble lubricant B. Ask the client to swallow water while the tube enters her throat C. Place the coiled tube in ice chips prior to insertion D. Tell the client to tilt her head backward as insertion begins E. Instruct the client to bear down during insertion

B. Provide oral hygiene frequently C. Measure the amount of drainage from the NG tube every shift D. Secure the NG tube to the client's gown

88. A nurse is planning care for a client who has a single-lumen nasogastric (NG) tube for gastric decompression. Which of the following actions should the nurse include in the plan of care? ( SATA ) A. Set the suction machine at 120 mmHg B. Provide oral hygiene frequently C. Measure the amount of drainage from the NG tube every shift D. Secure the NG tube to the client's gown E. Apply petroleum jelly to the client's nares

C. Pinch the NG tube while removing the tube

89. 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? A. Maintain suction while removing the NG tube B. Instill 100 mL of air into the NG tube before removal C. Pinch the NG tube while removing the tube D. Instruct the client to breathe in and out during the removal of the NG tube

A. Collect the specimen when the client rises in the morning

90. A nurse is planning care for a client who has a prescription for collection of a sputum specimen for culture and sensitivity. Which of the following actions should the nurse take when obtaining the specimen? A. Collect the specimen when the client rises in the morning B. Force fluids during the day and collect the specimen in the evening C. Collect the specimen after antibiotics have been started D. Collect 2 mL of sputum before sending the specimen to the laboratory

A. 2mm

91. After assessing a client, the nurse documents "1+ pedal edema bilaterally." This indicates that the nurse observed an indentation of which of the following depths after applying pressure? A. 2mm B. 4mm C. 6mm D. 8mm

B. Elevate the head of the bed to 30 or 40 degrees

92. A nurse is caring for an adult client who has an NG tube in place and a prescription for continuous enteral feedings. Which of the following actions should the nurse perform to reduce the client's risk of aspiration? A. Irrigate the tubing with 30 mL of sterile water B. Elevate the head of the bed to 30 or 40 degrees C. Suggest changing the feeding to lactose-free formula D. Warm the enteral formula to room temperature before feeding

A. A client who has heart failure and is receiving 100% oxygen via partial rebreather mask

94. A nurse is planning care for a group of clients receiving oxygen therapy. Which of the following clients should the nurse plan to see first? A. A client who has heart failure and is receiving 100% oxygen via partial rebreather mask B. A client who has emphysema and is receiving oxygen at 3L/min via transtracheal oxygen cannula C. A client who has an old tracheostomy and is receiving 40% humidified oxygen via tracheostomy collar D. A client who has COPD and is receiving oxygen at 2L/min via nasal cannula

B. Offer the client tart or sour foods first

96. A nurse is caring for an older adult client who has dysphagia following a cerebrovascular accident. Which of the following actions should the nurse take when assisting the client at mealtime? A. Encourage the client to drink fluids before swallowing food B. Offer the client tart or sour foods first C. Tilt the client's head backward when swallowing D. Turn on the television

B. Place the client in a supine position with the hips and knees flexed D. Cover the wound and intestine with a sterile, moistened dressing E. Monitor the client for manifestations of shock

97. A nurse is caring for a client who reports feeling a pop after coughing without properly splinting an abdominal incision. On assessment, the nurse notes that the client's wound has eviscerated. Which of the following actions should the nurse take? (SATA) A. Carefully reinsert the intestine through the opening in the wound B. Place the client in a supine position with the hips and knees flexed C. Leave the room to call the surgeon D. Cover the wound and intestine with a sterile, moistened dressing E. Monitor the client for manifestations of shock

D. Chronic hypoxemia

98. A nurse documents the presence of clubbing of the fingernails for a client who has emphysema. Which of the following is the underlying cause of this finding? A. Trauma B. Severe infection C. Iron D. Chronic hypoxemia

D. Right communication

99. A nurse delegates the collection of a client's temperature to an 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? A. Right task B. Right circumstance C. Right person D. Right communication