fundamentals 1

When admitting a client, the nurse records which information in the client's record first?

Asessment of the client

A client scheduled for a hysterectomy has not yet signed the operative consent form. When the nurse approaches the client and asks that she review and sign the form, the client says she no longer wants to have the surgery. At this time, which action should the nurse take?

Ask the client why she has changed her mind.

While measuring a client's vital signs, the nurse notices an irregularity in the heart rate. Which nursing action is appropriate?

Count the apical pulse rate for 1 full min, and describe the rhythm in the chart.

A nurse's neighbor is scheduled for elective surgery. The neighbor's provider indicated that a moderate amount of blood loss is expected during the surgery, and the neighbor is anxious about acquiring an infection from a blood transfusion. Which of the following is appropriate for the nurse to suggest?

Donating autologous blood before the surgery

Which of the following should a group of community health nurses plan as part of a primary prevention program for occupational pulmonary diseases?

Elimination of the exposure

A nurse is caring for an older adult client who is confused and continually grabs at the nurses. Which of the following is an nursing action?

Firmly tell the client not to grab

At the surgical scrub sink, a surgical nurse demonstrates the proper surgical handwashing technique by scrubbing

with her hands held higher than her elbows.

A nurse tells a client that the provider has prescribed IV fluids. The client appears to be upset about the IV catheter insertion, but says nothing to the nurse. Which of the following of the following is an appropriate nursing response?

"Is there something about this procedure that concerns you?"

An assistive personnel (AP) says to the nurse, "This client is incontinent of stool three or four times a day. I get angry, and I think that the client is doing it just to get attention. I think we should put adult diapers on her." Which is the appropriate nursing response?

"It is very upsetting to see an adult client regress."

A nurse is caring for a client just diagnosed with type 1 diabetes mellitus. The client is resistant to learning self injection of insulin and asks the nurse to administer all the injections. The nurse explains the importance of learning self care and appropriately adds which of the following statements?

"Tell me what I can do to help you overcome your fear of giving yourself injections."

An older adult client appears agitated when the nurse requests that the client's dentures be removed prior to surgery and states, "I never go anywhere without my teeth." Which of the following is an appropriate nursing response?

"You seem worried. Are you concerned someone may see you without your teeth?"

A nurse is planning interventions for a group of clients who are obese. What can the nurse do to improve their commitment to a long term goal of weight loss?

Attempt to develop the clients' self-motivation.

A nurse on a rehabilitation unit is transferring a client from a bed to a chair. To avoid a back injury, which of the following techniques should the nurse use?

Bend at the knees while maintaining a wide stance and a straight back, with the client's hands on the nurse's shoulders, and the nurse's hands under the client's axillae.

A client who is unstable and requires frequent vital signs has an electronic blood pressure machine automatically measuring his blood pressure every 15 min. However, the machine is reading the client's blood pressure at more frequent intervals, and the readings are not similar. The nurse checks the machine settings and observes the additional readings, but the problem continues. Which of the following is the appropriate nursing action?

Disconnect the machine, and measure the blood pressure manually every 15 min.

An older adult client just diagnosed with colon cancer asks the nurse what the primary care provider is going to do. The provider will be making rounds within the hour. Which of the following nursing actions is appropriate?

Help the client write down the questions to ask the provider, so that the client doesn't forget.

A nurse is caring for a client who requires rectal temperature monitoring. Available at the client's bedside is a thermometer is with a long, slender tip. Which of the following is the appropriate action for the nurse to take?

Obtain a thermometer with a short, blunt insertion end.

A nurse is caring for a client who has hypertension. Which approach is the priority when the nurse is measuring the client's blood pressure?

Obtain the blood pressure under the same conditions each time

While starting an intravenous infusion (IV) for a client, the nurse notices that her gloved hands get spotted with blood. The client has not been diagnosed with any infection transmitted via the bloodstream. Which of the following should the nurse do as soon as the task is completed?

Remove the gloves carefully and follow with hand hygiene.

At a mobile screening clinic, a nurse is assessing a client who reports a history of a heart murmur due to aortic stenosis. To auscultate the aortic valve, the nurse should place the stethoscope at which location?

Second intercostal space to the right of the sternum.

A client admitted with abdominal pain tells the nurse that her father died recently, and she begins crying while talking about him. The nurse determines that the client's temperature is 39.2° C (102.6° F), her abdomen is soft without tenderness, and her menses is overdue by 2 days. To which observation should the nurse give priority attention?

The client's temperature

When initiating cardiopulmonary resuscitation (CPR), the nurse must confirm which of the following assessment findings prior to beginning chest compressions?

absence of pulse

A postoperative client has been diagnosed with paralytic ileus. When performing auscultation of the client's abdomen, the nurse expects the bowel sounds to be

absent

A hospitalized client needs a chest x ray. The radiology department calls the nursing unit and says that they are sending a transporter for the client. When entering the client's room, the priority action is to

check bracelet

A nurse is precepting a newly licensed nurse who is preparing to help a client perform tracheostomy care. The nurse should intervene if the equipment the preceptee gathered included

cotton balls

A nurse is caring for a client diagnosed with a terminal illness. The client asks several questions about the nurse's religious beliefs related to death and dying. An appropriate nursing response is to

encourage the client to express his thoughts about death and dying.

A client is admitted to the hospital with decreased circulation in the left leg. During the admission assessment, which is the most important nursing action initially?

evaluation of pedal pulses

A 3 year old child has had multiple tooth extractions while under general anesthesia. The client returns from the postanesthesia care crying, but awake, from the recovery room. Which approach is likely to be successful?

examine the mouth last

Before donning gloves to perform a procedure, proper hand hygiene is essential. The nurse understands that the most important aspect of hand hygiene is the amount of

friction

A client comes to the emergency department reporting that he has had diarrhea for 4 days and is urinating less than usual. When assessing the client's skin turgor, the nurse should

grasp a fold of skin on the chest under the clavicle, release it, and note if it springs back.

An assistive personnel (AP) tells the nurse, "I am unable to find a large blood pressure cuff for a client who is obese. Can I just use the regular cuff if I can get it to stay on?" The nurse replies that taking the blood pressure of a morbidly obese client with a regular blood pressure cuff will result in a reading that is

high

A nurse is performing an abdominal assessment of an adult client. Identify the correct sequence of steps used for this assessment. (Move the sequence of steps into the box on the right, placing them in the selected order of performance. All steps must be used.)

inspection auscultation percussion palpate

A nurse is teaching a client who has cardiovascular disease how to reduce his intake of sodium and cholesterol. The nurse understands that the most significant factor in planning dietary changes for this client is the

involvement of the client in planning the change.

A nurse prepares to admit a client who is immediately postoperative to the unit following abdominal surgery. When transferring the client from the gurney to the bed, the nurse should

lock the wheels on the bed and strecher

To use the nursing process correctly, the nurse must first

obtain information about the client

Which of the following should the nurse do first when preparing to provide tracheostomy care?

perform hand hygiene

When assessing a client's heart sounds, the nurse hears a scratching sound during both systole and diastole. These sounds become more distinct when the nurse has the client sit up and lean forward. The nurse should document the presence of a(n)

pericardial friction

To use proper body mechanics while making an occupied bed for a client on bed rest, the nurse should

place the bed in a high horizontal position.

A nurse is demonstrating postoperative deep breathing and coughing exercises to a client about to undergo emergency abdominal surgery for appendicitis. The nurse realizes the client may be unprepared to learn if the client

reports severe pain

A client is admitted to the hospital in the terminal stage of cancer. The nurse enters the client's room to administer medications and finds the client crying. The appropriate nursing action is to

sit and hold the client's hand

A nurse admits a client to a same-day surgery center for an exploratory laparotomy procedure this morning. The client's surgeon asks the nurse to witness the signing of the preoperative consent form. In signing the form as a witness, the nurse affirms that

the signature on the preoperative consent form is the client's.