Fundamentals 1

nurse caring for client who is unstable & has vital signs measured every 15 mins by an electronic BP machine Nurse notices machine begins to measure BP at varied intervals & readings are inconsistent. Which of following actions should nurse take?

Discontinue machine, & measure BP manually every 15 min. If nurse questions reliability of monitoring equipment, a manual process should be used. Also, malfunctioning equipment can pose safety risk for client, so it must be tagged &removed.

nurse at screening clinic assessing client who reports history of heart murmur related to aortic valve stenosis. At which of following anatomical areas should nurse place stethoscope to auscultate aortic valve?

Second intercostal space to right of sternum. aortic valve is located in the second intercostal space to right of the sternum. Aortic stenosis produces mid systolic ejection murmur that can be heard clearly at aortic area with client leaning forward.

nurse caring for an older adult client who becomes agitated when nurse requests that client's dentures be removed prior to surgery. Which of following responses should nurse make?

"What worries you about being without your teeth?" Response by nurse therapeutic because it validates client's feelings of agitation and seeks reason for it.

nurse in an oncology clinic is assessing client who is undergoing treatment for ovarian cancer. Which of following statements by client indicates she experiencing psychological distress?

"I keep having nightmares about my upcoming surgery." nurse should recognize that nightmares and sleep disturbances are manifestations of anxiety & post-traumatic stress disorder. These indicate that client is at risk for experiencing psychological distress.

nurse teaching group of older adults about expected changes of aging. Which of following statements by group member indicates that teaching has been effective?

"I should expect my heart rate to take longer to return to normal after excessive as I get older." Older adults experience decreased cardiac output, which causes increased pulse rate during exercise. However, pulse rate also takes longer to return to normal after exercise.

nurse providing teaching to an older adult client who has constipation. Which of following statements should nurse include in teaching?

"Sit on toilet 30 minutes after eating meal." Increased peristalsis occurs after food enters the stomach. Sitting on toilet 30 min after eating meal, regardless of feeling the urge to defecate, is recommended method of bowel retraining to treat constipation.

nurse caring for client who has type 1 diabetes mellitus & is resistant to learning self-injection of insulin. Which of following statements should nurse make?

"Tell me what I can do to help you overcome your fear of giving yourself injections." response illustrates therapeutic communication technique of clarifying & offering of self. It is important for nurse to allow client to express feelings & fears and to support client in learning how to give injections.

nurse teaching an assistive personnel (AP) about proper hand hygiene. Which of following statements by AP indicates an understanding of teaching?

"There are times I should use soap & water rather than alcohol based hand rub to clean my hands." While alcohol-based hand rubs are as effective as soap & water in providing proper hand hygiene, Center for Disease Control & Prevention recommends washing hands with soap & water at certain times, such as when hands are visibly soiled with dirt or body fluids.

nurse observes an assistive personnel (AP) preparing to obtain BP with regular size cuff for client who is obese. Which of following explanations should nurse give AP

"Using cuff that too small will result in an inaccurately high reading." Blood pressure cuffs come in various sizes, and the correct size cuff is necessary to obtain reliable measurement. Blood pressure readings can be falsely high if cuff too small for client.

nurse caring for client who is postoperative & has paralytic ileum. Which of following abdominal assessments should nurse expect?

Absent bowel sounds with distention. Paralytic ileus is an immobile bowel. With this disorder, bowel sounds are absent & abdomen is distended.

nurse caring for child who is postoperative following tonsillectomy. Which of following actions should nurse take?

Administe analgesics to child on routine schedule throughout day & night. o soothe client's throat following tonsillectomy, nurse should administer pain medication routinely around the clock. Nurse can provide medication rectally or intravenously to avoid oral route.

nurse planning weight loss strategies for a group of clients who are obese. Which of following actions by nurse will improve client's commitment to long-term goal of weight loss?

Attempt to increase client's self-motivation Motivation to learn is important in improving a client's commitment to achievement of health goal, as well as increasing amt & speed of learning.

nurse inserting an IV catheter for client that results in blood spill on her gloved hand. Client has no documented bloodstream infection. Which of following actions should nurse take?

Carefully remove gloves & follow with hand hygiene. Standard precautions require use of gloves & hand hygiene in care of all clients.

nurse measuring vital signs for client & notices an irregularity in pulse. Which of following actions should nurse take?

Count apical pulse rate for 1 full min, & describe rhythm in chart. If peripheral pulse is irregular, nurse should auscultate apical pulse for 60 seconds to obtain an accurate rate. Nurse should document irregularity in client's medical record.

nurse caring for client who has terminal illness. Client asks several questions about nurse's religious beliefs related to death & dying. Which of following actions should nurse take?

Encourage client to express his thoughts about death & dying. Nurse should recognize client's need to talk about impending death & should encourage client to discuss his thoughts on subject. Therapeutic technique of reflecting. Depending on situation, nurse can also share some thoughts on this topic. Self-disclosure is communication skill that can help open lines of communication when appropriate. If nurse does not want to share personal beliefs, communication skills of offering self and listening to client's thoughts are appropriate.

nurse an emergency department assessing a client who reports diarrhea & decreased urination for 4 days. Which of following actions should nurse take to assess client's skin turgor?

Grasp skin fold on chest under clavicle, release it, & note whether it springs back nurse should use this technique for collecting data on skin turgor. If client has good turgor and is properly hydrated, skin will immediately return to normal; with dehydration, skin will remain tented. Nurse can also collect data on skin turgor by grasping a skin fold on back of forearm.

nurse caring for client who requires chest x-ray. Prior to client being transported for procedure, which of following actions should nurse take first?

Identify client using two identifiers. nurse should apply safety and risk reduction priority-setting framework when caring for this client. This framework assigns priority to factor or situation posing greatest safety risk to the client. When there are several risks to client safety, one posing the greatest threat is the highest priority. Nurse should use Maslow's hierarchy of needs, the ABC priority-setting framework, or nursing knowledge to identify which risk poses greatest threat to client. Once the client's identity is determined, nurse can then proceed with other options. This action is priority action because it provides for safety of the client. It is nursing responsibility to be certain that each client receives only what has been prescribed. Nurse must assure that correct client is being transported for a chest x-ray.

nurse performing an abdominal assessment for an adult client. Identify correct sequence of steps for this assessment.

Inspect, Auscultate, Percuss, Palpate appropriate sequence for nurse to perform abdominal data collection is to inspect, auscultate, percuss, & then palpate. This sequence prevents altering the bowel sounds & causing false results. Appropriate sequence for any other data collection for an adult client is inspection, palpation, percussion, & auscultation.

nurse receiving client from the PACU who is postoperative following abdominal surgery. Which of following actions should nurse take to transfer client from stretcher to bed?

Lock wheels on bed & stretcher.. Locking wheels prevents client from falling to floor by not allowing cart or bed to move apart or away from client.

nurse preparing client who is scheduled for hysterectomy for transport to operating room when client states she no longer wants to have surgery. Which of following actions should nurse take?

Notify provider about client's decision Acting as client advocate, nurse should support client in her decision notify provider.

charge nurse observing newly licensed nurse perform tracheostomy care for client. Which of following actions by newly licensed nurse requires intervention?

Obtaining cotton balls for tracheostomy care.. Cotton ball particles can be aspirated into tracheostomy opening, possibly causing tracheal abscess. Charge nurse should intervene for this action.

nurse preparing to provide tracheostomy care for client. Which of following actions should nurse take first?

Perform & hygiene According to evidence-based practice, nurse should 1st perform hand hygiene before touching client or performing any skills, such as tracheostomy care. This is vital because contamination of nurse's hands is a primary source of infection.

nurse obtaining BP in client's lower extremity. Which of following actions should nurse take?

Place bladder of cuff over posterior aspect of thigh. correct position for nurse to place bladder of cuff when measuring a lower extremity blood pressure.

nurse on rehabilitation unit preparing to transfer client who is unable to walk from bed to wheelchair. Which of following techniques should nurse use?

Place wheelchair at 45 degree angle to bed. Positioning wheelchair at a 45° angle allows client to pivot, lessening amt of rotation required.

nurse caring for an older adult client who is violent & attempting to disconnect her IV lines. Provider prescribes soft wrist restraints. Which of following actions should nurse take while client is in restraints?

Remove restraints one at time.. nurse should remove one restraint at a time for client who is violent or noncompliant.

nurse caring for client who is in terminal stage of cancer. Which of following actions should nurse take when she observes client crying?

Sit & hold client's hand With this action, nurse uses therapeutic communication techniques of silence, touch, & offering of self to client.

nurse planning to obtain vital signs of 2-yr-old child who is experiencing diarrhea & who might have right ear infection. Which of following routes should nurse use to obtain temperature?

Temporal. temporal artery route, while not as accurate as the rectal route for obtaining a precise body temperature, is non-invasive and can be used to obtain a temperature in a toddler who may have an ear infection and who is having diarrhea. The nurse should place the probe behind the ear if the client is diaphoretic, but should avoid placing it over an area covered with hair.

nurse demonstrating postoperative deep breathing & coughing exercises to client who will have emergency surgery for appendicitis. Which of following statements indicates lack of readiness to learn by client?

client reports severe pain. client who is experiencing severe pain not able to concentrate & not ready to learn new activity.

nurse providing teaching to client who has heart failure about how to reduce his daily intake of sodium. Which of following factors most important in determining client's ability to learn new dietary habits?

involvement of client in planning change. According to evidence-based practice, client involvement in planning dietary changes most important factor in client's ability to learn new habits.

nurse on medical-surgical unit washing her hands prior to assisting with surgical procedure. Which of following actions by nurse demonstrates proper surgical hand-washing technique?

nurse washes with her hands held higher than her elbows. Nurse who is performing surgical hand-washing technique should wash with her hands held higher than elbows so that water & soapsuds can drain away from clean area toward dirty area.

nurse witnessing client sign an informed consent form for surgery. Which of following describes what nurse affirming by this action?

signature on preoperative consent form client's. nurse acts as a witness to attest that it is client's signature on preoperative consent form. It is responsibility of provider who will perform procedure to obtain consent by explaining procedure along with associated risks & benefits.

nurse preparing to perform mouth care for an unresponsive client. Which of following actions should nurse plan to take?

Raise level of bed. nurse should raise bed to allow for use of proper body mechanics & reduce risk of self-injury.

community health nurse preparing campaign about seasonal influenza. Which of following plans should nurse include as secondary prevention?

Screening groups of older adults in nursing care facilities for early influenza manifestations. Screening older adults who have some manifestations of illness to determine if they have influenza is an example of secondary prevention. Secondary prevention is focused on preventing complications of an illness or providing care to prevent illness from becoming severe.

nurse on medical-surgical unit is caring for client. Which of following actions should nurse take first when using nursing process?

Obtain client information. nurse should apply nursing process priority-setting framework. Nurse can use nursing process to plan client care & prioritize nursing actions. Each step of nursing process builds on previous step, beginning with data collection. Before nurse can formulate plan of action, implement nursing intervention, or notify provider of change in client's status, she must 1st collect adequate data from client. Collecting additional data will provide nurse with knowledge to make an appropriate decision.

nurse providing preoperative teaching to client who is scheduled for arthroplasty in next mth that might require blood transfusion. Client expresses concern about risk of acquiring an infection from blood transfusion. Which of following statements should nurse make to client?

Donate autologous blood before surgery. Autologous blood transfusion collection & reinfusion of client's own blood. With preoperative autologous blood donation, blood is drawn from the client 3 to 5 weeks before an elective surgical procedure & stored for transfusion at time of surgery. Autologous blood safest form of blood transfusion; exclusive use of client's own blood eliminates exposure to transfusion-transmitted infection.

nurse admitting client who has decreased circulation in his left leg. Which of following actions should nurse take first?

Evaluate pedal pulses. client who has decreased circulation in leg, evaluating pedal pulses is critical in order to determine adequate blood supply to foot. The nurse should apply the safety & risk reduction priority-setting framework when caring for this client. When there are several risks to client safety, one posing greatest threat is highest priority. This framework assigns priority to factor posing greatest safety risk to client. When there are several risks to client safety, one posing greatest threat is highest priority. Nurse should use Maslow's Hierarchy of Needs, ABC priority-setting framework, or nursing knowledge to identify which risk poses greatest threat to client.

nurse planning care for client who reports abdominal pain. An assessment by nurse reveals client has temperature of 39.2 degrees C (102 degrees F), heart rate of 105/min, soft contender abdomen, & census overdue by 2 days. Which of following findings should be nurse's priority?

Temperature. Elevated temperature is an emergent physiological need which requires priority intervention by nurse. Nurse should consider Maslow's Hierarchy of Needs, which includes 5 levels of priority when answering this item. First level consists of physiological needs; Second level consists of safety & security needs; third level consists of love & belonging needs; fourth level consists of personal achievement & self-esteem needs; & fifth level consists of achieving full potential & ability to problem solve & cope with life situations. When applying Maslow's Hierarchy of Needs, nurse should review physiological needs first. Nurse should then address client's needs by following remaining four hierarchal levels. However, it is important for nurse to consider all contributing client factors, as higher levels of pyramid can compete with those at lower levels, depending on situation.

nurse on medical-surgical unit admitting a client. Which of following information should nurse document in client's record first?

Assessment/ data collection for client. Nurse should apply nursing process priority-setting framework. Nurse can use nursing process to plan client care & prioritize nursing actions. Each step of nursing process builds on previous step, beginning with assessment or data collection. Before nurse can formulate plan of action, implement nursing intervention, or notify provider of change in client's status, she must first collect adequate data from the client. Assessing or collecting additional data will provide nurse with knowledge to make an appropriate decision.

charge nurse teaching adult cardiopulmonary resuscitation (CPR) to group of newly licensed nurses. Which of following actions should charge nurse teach as first response in CPR?

Confirm unresponsiveness. nurse should apply nursing process priority-setting framework. Nurse can use nursing process to plan client care & prioritize nursing actions. Each step of nursing process builds on previous step, beginning with assessment or data collection. Before nurse can formulate a plan of action, implement nursing intervention, or notify provider of change in client's status, she must first collect adequate data from client. Assessing or collecting additional data will provide nurse with knowledge to make an appropriate decision. Establishing unresponsiveness required before beginning CPR. If client is unresponsive, nurse should activate emergency response team.

nurse assessing heart sounds of client who has developed chest pain that becomes worse wIth inspiration. Nurse auscultates high-pitched scratching sound during both systole & diastole with diaphragm of stethoscope positioned at left sternal border. Which of following heart sounds should nurse document?

Pericardial friction rub. pericardial friction rub has scratching, grating, or squeaking leathery sound. It tends to be high frequency & best heard with diaphragm of stethoscope at 3rd intercostals space of left sternal border. Pericardial friction rub manifestation of pericardial inflammation & can be heard with infective pericarditis, myocardial infarction, following cardiac surgery or trauma, & with some autoimmune problems, such as rheumatic fever. client who develops pericarditis typically has chest pain which becomes worse with inspiration or coughing & which may be relieved by sitting up & leaning forward.