FOUNDS EXAM 2 REVIEW QUESTIONS

The nurse is preparing to perform a blood glucose monitoring test on a patient. Place the steps for performing the procedure in a correct sequence

- Instruct patient to perform hand hygiene with soap & water. - Check code on test strip vial. - Press button on meter to confirm match codes. - Perform hand hygiene and put on clean gloves. - Clean patient finger with antiseptic swab. - Holding lancet to finger, press release button on machine. - Bringing meter to test strip, allow blood drop to wick onto test strip. -Interpret results and document.

A nurse is caring for a 76-year-old female patient in a home setting. She just lost her husband from COVID-19 and has four children who live nearby. The patient was an educator and retired only two years ago. The nurse supplies knowledge of developmental changes in the nature of loss in older adults, when assessing, which of the following situations?

- The nature of her relationships with her adult children -The patient perception of the need for caregiving assistance from the family with activities her husband performed -The impact of her husband's death on her monthly income -The patient's current physical functional status

Which nursing action does the nurse take when placing a bedpan under a patient who is immobilized?

- after positioning the patient on the bedpan, elevate the head of the bed to a 45-degree angle -make sure the patient has a nurse call system in reach to notify the nurse when ready to have a bedpan removed

A patient is receiving total parenteral nutrition (TPN). What are the primary interventions the nurse should follow to prevent a central line infection?

- change the dressing using sterile technique. - change the TPN tubing every 24 hours.

Which of the following nursing activities apply to an MDRPI?

- cushion at risk areas (ears, nose, with foam or protective dressing) - chose correct size of device -observe for erythema or irritation that conforms to pattern or shape of device -observe under cast and splits

A nurse is a 76-year-old woman in the outpatient clinic. The patient states she recently started to notice a glare the lights at home. Her vision is blurred, and she is unable to play with cards with her friends, read, or do her needlework. Which of the following nursing interventions are appropriate?

- refer her to an ophthalmologist - Suggest large print books and playing cards - Assess her home environment for safety

A daughter is beginning to assume caregiver responsibility for her 90 year old widowed father. Her father has hypertension, coronary artery, disease, and type two diabetes mellitus. Home health services are set for once a week. During the first visit, the daughter expresses concern about all the medication's that her father has been prescribed by different doctors that he is obtained from different pharmacies. The daughter states that her father cannot really tell her what each medication is for or when he should take them. From this initial information, the nurse suspects polypharmacy. What medication assessment data are needed?

- review all medication prescriptions - Match medication prescriptions with the patient's medication bottles or unit dose blister packs - Identify involvement of the caregiver and helping with medication administration - Obtain a listing of any over-the-counter medication's

The nurse is contacting the health care provider about a patients sleep problem. Place the steps of the SBAR (situation, background, assessment, recommendation) in the correct order.

-"Dr. Smithson, this is Pam, the nurse caring for Mrs. Dodd. I'm calling because Mrs. Dodd is having difficulty sleeping. -Mrs. Dodd, 46 years old, was admitted 3 days ago following a motor vehicle accident. She is in balanced skeletal traction for a fractured left femur. She is having difficulty falling asleep. -Mrs. Dodd is taking her pain medication every 4 hours as ordered and rates her pain as 2 out of 10. Last night she was still awake at 0100. She states that she is comfortable but just can't fall asleep. Her vital signs are BP 124/76, P 78, R 12 and T 37.1°C (98.8°F). -"I'm calling to ask if you would order a hypnotic such as zolpidem to use on a prn basis."

A nurse is teaching a patient about the warning signs of possible colorectal cancer according to the American Cancer Society guidelines. Which statement reflect that the patient understands the teaching?

-"I need to let my doctor know if my bowel habits start to change" -"Blood in my stool is one warning sign I need to look for." -"Some people with colorectal cancer have unexplained abdominal or back pain."

The nurse recognizes that which statements made by a patient indicate an understanding of behaviors that will promote sleep?

-"I will not watch television in bed." -"I will not drink caffeine later in the day." -"I will start to exercise regularly during the day."

Which nursing interventions should a nurse implement when removing an indwelling urinary catheter in an adult patient?

-Allow the balloon to drain into the syringe by gravity. -Initiate a voiding record/bladder diary

A patient is scheduled to have an intravenous pyelogram (IVP) tomorrow morning. Which nursing measures should be implemented before the test?

-Ask the patient about any allergies and reactions. -Ensure that informed consent has been obtained. -Instruct the patient that facial flushing can occur when the contrast medium is given.

After abdominal surgery, the patient is on the surgical unit with an indwelling urinary catheter placed. What aspects of care for this patient can be delegated to the assistive personnel (AP)?

-Assisting the nurse with patient positioning and maintaining privacy during catheter care -Reporting to the nurse any patient discomfort or fever -Reporting any abnormal color, odor, or amount of urine in the drainage bag

Which skin-care measures are used to manage a patient who is experiencing fecal and/or urinary incontinence?

-Frequent position changes -Using an incontinence cleaner -Applying a moisture barrier ointment

Which sleep-hygiene actions at bedtime can the nurse delegate to assistive personnel? (Select all that apply.)

-Giving the patient a back rub -Turning on quiet music -Dimming the lights in the patient's room

Which nursing interventions best promote effective sleep in an older adult?

-Limit fluids 2 to 4 hours before sleep. -Ensure that the room temperature is comfortably cool. -Provide warm covers.

What should the nurse teach a young woman with a history of UTIs about UTI prevention?

-Maintain regular bowel elimination -Wear cotton underwear -Cleanse the perineum from front to back

Which nursing interventions are appropriate to include in a plan of care to promote sleep for patients who are hospitalized?

-Plan vital signs to be taken before the patients are asleep. -Have patients follow at-home bedtime schedule. -Close the door to patients' rooms at bedtime.

Which of the following is an indication for a binder to be placed around a surgical patient with a new abdominal wound?

-Reduction of stress on the abdominal incision -provision of support to abdominal tissue when coughing or walking

A 63-year-old. Patient is retiring from his job at an accounting firm, where he was in a management role for the past 20 years. He's been with the same company for 42 years and was a dedicated employee. His wife is a homemaker. She raise their five children, babysits for their grandchildren as needed, and belongs to numerous church committees. What are the major psychosocial concerns for this patient?

-The loss of his work role -How's the wife may not expect assistance with household task and was babysitting the grandchildren

A patient has a three-way indwelling catheter and CBI complains of lower abdominal pain and distant ion after surgery. What should be the nurse's initial interventions?

-asses the patency of the drainage system -measure urine output

A nurse is participating in a health and wellness event at the local community center. A woman approaches with her father and relates that she is worried that her with her father is becoming more functionally impaired, and may need to move in with her the nurse ask about his ability to complete activities of daily living (ADLs) by asking, which of the following questions?

-describe any problems you have an sitting and getting up from your toilet -Tell me how often can you take a bath during the week and how are you bathe

After surgery the patient with a closed abdominal wound reports a sudden "pop" after coughing. When the nurse examines the surgical wound site, the sutures are open, and a small bowel sections are observed at the bottom of the now-opened wound m. Which are the primary nursing interventions?

-notify the health care provider -cover the area with sterile, saline soaked towels immediately

The nurse is caring for a patient with pneumonia, who has severe malnutrition. That patient's condition places her at risk for which of the following life-threatening complications during hospitalization?

-sepsis -hemorrhage -skin breakdown

A nurse is developing a plan of care for a patient who was diagnosed with narcolepsy. Which interventions should the nurse include on the plan?

-take breif naps, no longer than 20 mins, no more than twice a day - establish a regular exercise program - teach the patient about the side effects of modafinil

A 78-year-old male is going through preoperative screening and preparation for his surgery in 1 week. His wife is with him, and initially they both appear anxious. He will be undergoing a colon resection for colon cancer and will have a permanent colostomy. The nurse knows the patients age and developmental status will affect how the assessment is conducted. The nurse wants to provide a data base that will be useful to the nurses in the hospital and therefore applies clinical judgment appropriately though which of the following:

-when the patient has difficult remembering current medications, the nurse asks the wife to supplement information -the nurse anticipates the effect of the colostomy on functioning and asks the patient how he perceives life with a colostomy

Medical adhesives, such as tape securing a wound dressing, cause MARSI. Which of the following interventions reduce the risk for MARSI?

1. Gently loosen the ends of the tape and gently pull the outer end parallel with the skin surface toward the wound. 3. Apply adhesive remover. 4. Use Montgomery ties to secure the dressing.

Which skills does the nurse teach a patient with a new colostomy before discharge from the hospital? (Select all that apply.)

1. How to change the pouch 2. How to empty the pouch 3. How to open and close the pouch 5. How to determine whether the ostomy is healing appropriately

The nurse is changing the PN tubing. Which action should the nurse take to prevent an air embolus?

Have the patient turn on the left side and perform a valsalva maneuver.

A 72-year-old patient ask the nurse about using an over-the-counter antihistamine as a sleeping pill to help her get to sleep. What is the nurses best response?

"Antihistamines should not be used because they can cause confusion and increase your risk of falls."

The nurse recognizes that which statement made by the patient indicates an understanding of sleep-hygiene practices?

"I usually drink a cup of warm milk in the evening to help me sleep."

The registered nurse is teaching a nursing student about how to safely use a urinary catheter. Which statement made by the nursing student indicates ineffective learning.

"I will avoid draining urine from the tubing before ambulating"

A nurse is taking a sleep history from a patient. The nurse recognizes that which statement made by the patient needs further follow-up?

"It takes me about 45 to 60 minutes to fall asleep."

A mother brings her 4-year-old son into the health clinic for a checkup and tells the nurse practitioner that he is having sleep problems. The nurse practitioner provides teaching on sleep hygiene for toddlers. Which statement made by the mother indicates a need for further teaching?

"We will play hide and seek just before bed to wear him out."

Which interventions does the nurse include when educating a person with chronic constipation?

-increase fiber and fluids in the diet -exercise for 30 mins every day -schedule time to use the toilet at the same time every day

Place the following steps for insertion of an indwelling catheter in a female patient in appropriate order

1. Drape patient with the sterile square and fenestrated drapes. 2. Prepare sterile field and supplies. 3. Lubricate catheter. 4. Cleanse urethral meatus with antiseptic solution. 5. Insert and advance catheter. 6. When urine appears, advance another 2.5 to 5 cm. 7. Inflate catheter balloon. 8. Gently pull catheter until resistance is felt. 9. Attach drainage tubing.

A patient's family member is considering having her mother placed in a nursing center. The nurse has talked with the family before and knows that this is a difficult decision. Which of the following criteria does the nurse recommend in choosing a nursing center? (Select all that apply.)

2. Adequate staffing is available on all shifts. 3. Social activities are available for all residents. 5. Staff encourage family involvement in care planning and assisting with physical care.

Place the steps when performing wound irrigation of a large open wound in the correct sequence. 1. Use slow, continuous pressure to irrigate wound. 2. Attach 19-gauge angiocatheter to syringe. 3. Fill syringe with irrigation fluid. 4. Place biohazard bag near bed. 5. Position angiocatheter over wound.

4. Place biohazard bag near bed. 3. Fill syringe with irrigation fluid. 2. Attach 19-gauge angiocatheter to syringe. 5. Position angiocatheter over wound. 1. Use slow, continuous pressure to irrigate wound.

Place the steps for an ileostomy pouch change in the correct order. 1. Close the end of the pouch. 2. Measure the stoma. 3. Cut the hole in the wafer to fit around the stoma and not leave skin exposed to the effluent. 4. Press the pouch in place over the stoma. 5. Remove the old pouch. 6. Trace the correct measurement onto the back of the wafer. 7. Assess the stoma and the skin around it. 8. Cleanse and dry the peristomal skin.

5, 8, 7, 2, 6, 3, 4, 1

After assessing several clients, the nurse will determine which client will require parental nutrition

A client with severe malabsorption station disorder

What is a critical step when inserting an i dwelling catheter into a male patient?

Advance the catheter to the bifurcation of the drainage and balloon ports

A nurse is assessing an older adult brought to the emergency department fall in the fall and wrist fracture. The patient lives with her son, is very thin, and then kept, has a stage three pressure injury on her coccyx, and has old bruising to the extremities, in addition to our new bruises from the fall. Is all the questions to her caregiver son, who accompanied her to the hospital. What is the nurses next step?

Ask the son to step out of the room so that she can complete her assessment

Which action by the client indicates the need for further instruction on insulin administration

Aspirating before administering the dose

When repositioning an immobile patient, the nurse notices redness over the hip bone. What is indicated when a reddened area blanches on a fingertip touch?

Blanching hyperemia, indicating the attempt by the body to overcome the ischemic episode.

A nurse is teaching a patient to obtain a specimen for fecal occult blood testing using fecal immunochemical testing (FIT) at home. How does the nurse instruct the patient to collect the specimen?

Collect one fecal smear from three separate bowel movements.

A patient is receiving an enternal feeding at 65 ml/h. The GRV in 4 hours was 125mL. What is the priority nursing intervention?

Continue the feedings; this is normal gastric residual for this feeding

A nurse is completely a health history with the daughter of a newly admitted patient who is confused and agitated. The daughter reports that her mother was diagnosed with Alzheimer's disease 1 year ago but became extremely confused last evening and was hallucinating. She was unable to calm her, and her mother thought she was a stranger. On the basis of this history, the nurse suspects that the patient is experiencing:

Delirium

A nurse conducted an assessment of a new patient who came to the medical clinic. The patient is 82 years old and has had osteoarthritis for 10 years and diabetes mellitus for 20 years. He is alert but becomes easily distracted during the assessment. He recently moved to a new apartment, and his pet beagle died just 2 months ago. He is most likely experiencing:

Depression

To prevent an adverse outcome when providing care for a client experiencing diarrhea, which client data with the nurse closely monitor?

Fluid and electrolyte balance

stage 3 pressure injury

Full thickness loss of skin, in which adipose tissue (fat) is visible in the ulcer, the granulation tissue and epibole (round wound edges) are often present. Slough and/or Escher may be visible. The depth of the tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds

unstageable pressure injury

Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or Escher is removed, a stage 3 or stage 4 pressure injury will be revealed.

stage 4 pressure injury

Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occurs. Depth varies by anatomical location.

When a clients total parenteral nutrition bag is empty which action is appropriate for the nurse to take

Hang a bag of 10% dextrose at the ordered TPN rate and place an urgent request for the next TPN bag

Which nursing intervention decreases the risk for CAUTI?

Hanging the urinary drainage bag below the level of the bladder

The nurse is teaching a client about safe insulin administration. Which statement made by the client indicates the need for further education?

I should administer insulin only if there are any symptoms

Which statement made by the parents of a 2-month-old infant requires further education by the nurse?

I'm going to alternate formula with whole milk starting next month.

Which intervention would prevent urinary status information of renal calculi in an immobile client?

Increasing oral fluid intake to 2 to 3 L/day

What should the nurse teach family caregivers when a patient has fecal inconvenience because of cognitive impairment?

Initiate a bowel or habit training program to promote continence

The nurse is preparing to change a client stressing. For which reason with the nurse you surgical asepsis.

Keeps the area free from micro organisms

The nurse would expect to find an increase of which substance in the urine other client following a low carbohydrate diet

Ketones

The patient states "I have diarrhea hand cramping every time I have ice cream. I am sure this is because the food is cold." Based on this assessment data, which health problem does the nurse suspect?

Lactose intolerance

The nurse is inserting a urinary catheter for a female patient, and after the catheter has been inserted 3 inches, no urine is returned. What should the nurse do next?

Leave the catheter there and start over with a new catheter.

The client reports abdominal cramping while undergoing a soapsuds enema, which action would the nurse take?

Lower the height of the enema bag

Which risk factors regarding fall prevention and safety for older adults with the nurse manager, include in a presentation to a group of nurses?

Medication's, visual changes, orthostatic hypotension

Which rational is correct for the nurse to empty a Hemovac room suction device when it is half full

Negative pressure in the unit lessons as fluid accumulates , interfering with further drainage

The nurse is caring for an older adult client who has constipation. Which independent nursing intervention best helps reestablish a normal bowel pattern?

Offer a cup of prune juice

When monitoring a client, 24 to 48 hours after abdominal surgery, the nurse would assess which problem associated with anesthetic agents?

Paralytic ileus

Which action can a nurse delegate to AP

Performing glucose monitoring every 6 hours on a stable patient

A nurse sees an AP perform the following interventions for a patient receiving continuous enternal feedings. Which action would require immediate attention by the nurse?

Placing patient supine while giving a bath

Which instruction should the nurse give the assistive personnel (AP) concerning a patient who has had an indwelling urinary catheter removed that day?

Report the time and amount of first voiding

The nurse is caring for a patient with dysplasia and is feeding her a puréed chicken diet. Suddenly the patient begins to choke. What is the priority nursing intervention?

Stop feeding her

during the administration of a warm tap-water enema, a patient starts to have cramping abdominal pain that he rates a 6 out of 10. What nursing action should the nurse take first.

Stop the instillation

Which findings noted during assessment would lead the nurse to determine that a client is at an increased risk for infection?

Surgical incision, urinary catheter, antibiotic therapy, intravenous access

At which side with the nurse, obtain a sterile your analysis for my client with an indwelling catheter

Tubing injection port

Which nurses action would prevent aspiration when administering medication through a nasogastric tube?

Verify placement of the nasogastric tube

Which instruction is important for the nurse to include in discharge teaching for a client who has to perform intermittent urinary self catheterization?

Wash your hands before performing the procedure

A patient is receiving both PN and EN. When would the nurse collaborate with the health care provider and request a discontinuation of PN?

When 75% of the patients nutritional needs are met by the tube feedings

A client with dementia is confused about what day it is. Which statement made by the nurse is an example of validation therapy?

Yes, today is the day that you just mentioned

What is the removal of devitalized tissue from a wound called

debridement

stage 1 pressure injury

intact skin with localized area of non-blanchable erythema, which may appear differently in darkly pigmented skin. Presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep-pressure injury

stage 2 pressure injury

partial thickness skin loss with exposed dermis. The wound bed is visible, pink or red, and moist, and may also present as an intact or ruptured serum-filled blister. Adipose tissue (fat) and deeper tissues are not visible.

Which of the following are measures to reduce tissue damage from shear?

—Use a transfer device, e.g. transfer board -Have head of bed flat when re positioning patients -Raise head of bed 30 degrees when patient positioned supine