Fundamentals 1 Quiz
A nurse is admitting a client who has decreased circulation in his left leg. Which of the following actions should the nurse take first? A) Evaluate pedal pulses B) Obtain medical history C) Measure vital signs D) Assess for leg pain
A For a client who has decreased circulation in the leg, evaluating pedal pulses is critical in order to determine adequate blood supply to the foot. The nurse should apply the safety and risk reduction priority-setting framework. This framework assigns priority to the factor posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's Hierarchy of Needs, the ABC priority-setting framework, or nursing knowledge to identify which risk poses the greatest threat to the client.
A nurse is receiving a client from the PACU (post-anesthetic care unit) who is postoperative following abdominal surgery. Which of the following actions should the nurse take to transfer the client from stretcher to the bed? A) Lock the wheels on the bed and stretcher B) Instruct the client to raise his arms above his head C) Elevate the stretch 2.5 cm (1 inch) above the height of the bed D) Log roll the client
A Locking the wheels prevents the client from falling to the floor by not allowing the cart of bed to move apart or away from the client.
A nurse is teaching a group of older adults about expected changes of aging. Which of the following statements by a group member indicates that the teaching has been effective? A) "I should expect my heart rate to take longer to return to normal after exercise as I get older" B) "Urinary incontinence is something I will have to live with as I grow older" C) "I can expect to have less ear was as I get older" D) "My stomach will empty more quickly after meals as I grow older"
A Older adults experience decreased CO, which causes increased pulse rate during exercise. The pulse rate also takes longer to return to normal after exercise.
A nurse is demonstrating postoperative deep breathing and coughing exercises to a client who will have emergency surgery for appendicitis. Which of the following statements indicates a lack of readiness to learn by the client? A) The client asks the nurse to repeat the instructions before attempting the exercises. B) The client reports severe pain C) The client asks the nurse how often deep breathing should be done after surgery. D) The client tells the nurse that this exercise will probably be painful after surgery.
B A client who is experiencing severe pain is not able to concentrate and therefore, is not ready to learn a new activity
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 intervention? A) Obtaining hydrogen peroxide for the tracheostomy care b) Obtaining cotton balls for the tracheostomy care c) Obtaining sterile gloves for the tracheostomy care d) Obtaining a sterile brush for the tracheostomy care
B Cotton ball particles can be aspirated into the tracheostomy opening, possibly causing a tracheal abscess. The charge nurse should intervene for this action
A nurse is measuring vital signs for a client and notices an irregularity in the pulse. Which of the following actions should the nurse take? A) Measure the pulse using a Doppler ultrasound stethoscope. B) Check the client's pedal pulses. C) Count the apical pulse rate for a full minute and describe the rhythm in the chart. D) Take the pulse at each peripheral site and count the rate for 30 seconds.
C If the peripheral pulse is irregular, the nurse should auscultate the apical pulse for 1 minute to obtain an accurate rate. The nurse should document irregularity in the client's medical record.
A nurse is assessing the heart sounds of a client who has developed chest pain that becomes worse with inspiration. the nurse auscultates a high-pitched scratching sound during both systole and diastole with diaphragm of the stethoscope positioned at the left sternal border. Which of the following heart sounds should the nurse document? A) Audible click B) Murmur C) Third heart sound D) Pericardial friction rub
D A pericardial friction rub has a high-pitched scratching, grating, or squeaking leathery sound heard best with the diaphragm of the stethoscope at the left sternal border. A pericardial friction rub is a manifestation of pericardial inflammation and can be heard with infective pericarditis with myocardial infarction, following a cardiac surgery or trauma, and with some autoimmune problems, such as rheumatic fever. The client who develops pericarditis typically has chest pain which becomes worse with inspiration or coughing and which may be relieved by sitting up and leaning forward.
A nurse is caring for a client who is postoperative and has paralytic ileum. Which of the following abdominal assessments should the nurse expect? A) Frequent bowel sounds with flatus B) Absent bowel sounds with distention C) Hyperactive bowel sounds with diarrhea D) Normal bowel sounds with increased peristalsis
B Paralytic ileus is an immobile bowel. With this disorder, bowel sounds are absent and the abdomen is distended
A nurse is providing teaching to an older adult client who has constipation. Which of the following statements should the nurse include in the teaching? A) "Drink a minimum of 1,000 ml of fluid daily" B) "Increase your intake of refined-fiber foods" C) "Sit on the toilet 30 mins after eating a meal" D) "Take a laxative everyday to maintain regularity"
C Increased peristalsis occurs after food enters the stomach. Sitting on the toilet 30 min after eating a meal, regardless of feeling the urge to defecate, is a recommended method of bowel retraining to treat constipation
A nurse is preparing to provide tracheostomy care for a client. Which of the following actions should the nurse take first? A) Open all sterile supplies and solutions. B) Stabilize the tracheostomy tube. C) Don sterile gloves. D) Perform hand hygiene.
D According to evidence-based practice, the nurse should first perform hand hygiene before touching the client or performing any skills, such as tracheostomy care. This is vital because contamination of the nurse's hands is a primary source of infection.
A nurse is providing preoperative teaching to a client who is scheduled for arthroplasty in the next month that might require a blood transfusion. The client expresses concern about the risk of acquiring an infection from the blood transfusion. Which of the following statements should the nurse make to the client? A) "Ask your provider to prescribe epoetin before the surgery" B) "You should ask your provider about taking iron supplements prior to the surgery" C) "Request a family member to donate blood for you" D) "Donate autologous blood before the surgery"
D Autologous blood transfusion is the collection and reinfusion of the client's blood. With preoperative autologous blood donation, the blood is drawn from the client 3-5 week before an elective surgical procedure and stored for transfusion at the time of the surgery. Autologous blood is the safest form of blood transfusion because exclusive use of a client's own blood eliminates exposure to transfusion-transmitted infection.
A nurse observes an assistive personnel (AP) preparing to obtain blood pressure with a regular size 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"
D Blood pressure cuffs come in various sizes, and the correct size cuff is necessary to obtain a reliable measurement. Blood pressure readings can be falsely high if the cuff is too small for the client.
A nurse is caring for a client who has type 1 diabetes mellitus and is resistant to learning self-injection of insulin. Which of the following statements should the nurse make? A) "Tell me what I can do to help you overcome your fear of giving yourself injections" b) "I am sure your provider will not be pleased that you refuse to give yourself insulin injections" C) "It's okay. I'm sure your partner will be able to learn how to give you the insulin injections" D) "You won't be able to go home unless you learn to give yourself insulin injections"
A The response illustrates the therapeutic communication technique of clarifying and offering of self. It is important for the nurse to allow the client to express feelings and fears and to support the client in learning how to give the injections.
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? A) Change the topic because the client is trying to divert attention from the illness to the nurse. B) Encourage the client to express his thoughts about death and dying? C) Tell the client that religious beliefs are a personal matter. D) Offer to contact the client's minister or the facility's chaplain.
B A nurse should recognize the client's need to talk about impending death, and encourage the client to discuss his thoughts on the subject. This is therapeutic technique of reflecting. Depending on the situation, the nurse can also share some thoughts on this topic. Self-disclosure is a communication skill that can help open lines of communication when appropriate. If the nurse does not want to share personal beliefs, the communication skills of offering self and listening to the client's thoughts are appropriate.
A nurse on a med-surg unit is caring for a client. Which of the following actions should the nurse take first when using the nursing process? A) Identify goals for client care. B) Obtain client information C) Document nursing care needs D) Evaluate the effectiveness of care
B The nursing process is based on scientific process. The first step in the scientific process is the collection of data. Therefore, the first step is assessing and obtaining information about the client.