Fundamentals

A nurse is reinforcing teaching with the parent of a child who is to take 10 mL of a liquid medication. The parent has a hollow medication spoon with marks to indicate teaspoons and tablespoons. How many teaspoons should the nurse instruct the parent to give the child?

2. Follow these steps for the conversions of mL to tsp: Step 1: What is the unit of measurement the nurse should calculate? tsp Step 2: Set up an equation and solve for X. 5 mL/1 tsp= 10 mL/X tsp 5X=10 X=2 Step 3: Round if necessary. Step 4: Determine whether the conversion to tsp makes sense. If 5 mL=1 tsp, then 10 mL=2 tsp

A nurse is receiving a client from the PACU who is postoperative following abdominal surgery. Which of the following actions should the nurse take to transfer the client from the 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 stretcher 2.5 cm (1 in) 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 or bed to move apart or away from the client.

A nurse is reinforcing teaching with 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 wax as I get older." D. "My stomach will empty more quickly after meals as I grow older."

A. Older adults experience decreased cardiac output, which causes increased pulse rate during exercise. However, the pulse rate also takes longer to return to normal after exercise.

A nurse is reinforcing teaching with a client who needs to reduce cholesterol levels. Which of the following foods should the nurse suggest that the client add to his diet? A. Carrot B. Porkchop C. Shrimp D. Egg yolks

A. Plant foods like carrots contain no cholesterol; foods from animal sources contain cholesterol.

A nurse is reinforcing teaching with a middle adult client about health promotion and disease prevention. The nurse should remind the client that which of the following changes should occur? A. Decreased estrogen and testosterone production B. Increased tone of the large intestines C. Increased percentage of the body's muscle mass D. Decreased incidence of chronic illness

A. Both estrogen and testosterone levels start to decrease in middle age.

A nurse rates a client's biceps reflex as 2+. Which of the following characteristics should the nurse document about the client's reflexes? A. Diminished B. Average C. Brisk D. Hyperactive

B. Reflexes range on a scale of 0 to 4+. Active or expected reflexes are 2+.

A nurse is collecting data from a client who requires hygiene care. Which of the following pieces of information is the nurse's priority to determine before preparing to bathe the client? A. What type of soap and lotion the client uses at home B. How much the client can assist with bathing C. Whether the client usually bathes in the morning or in the evening D. How important daily bathing is to the client

B. The greatest risk to the client's safety is an injury resulting from an overestimation of the client's ability to help with hygiene care. Therefore, the nurse's priority is to collect data about the client's muscle strength, flexibility, vision, cognition, and sensation and to adjust hygiene procedures accordingly to ensure safety.

A nurse is implementing cold therapy for a client who has an ankle sprain. Which of the following actions should the nurse take? A. Apply a cold pack to an area that is edematous B. Check capillary refill before applying an ice pack to the affected area C. Fill an ice pack half full of crushed ice D. Apply an ice pack for 60 minute intervals

B. The nurse should assess the affected area for adequate circulation by checking pulses and capillary refill because a cold pack applied to an area of impaired circulation can further decrease the blood supply to the area.

A nurse is collecting health history data from a client who is deaf and uses American Sign Language (ASL) to communicate. The nurse will be working with an ASL interpreter. Which of the following actions should the nurse perform when working with the interpreter? A. Face away from the client to avoid creating a distraction B. Pace speech to allow time for the interpreter to convey the words C. Make eye contact with the interpreter when explaining the procedure D. Stand in the background while the interpreter translates the message

B. The nurse should speak distinctly and a rate that allows time for the interpreter to convey the message and for the client to receive it.

A nurse is collecting data about a client's vascular system. Which of the following techniques should the nurse use when evaluating the carotid arteries? A. Palpation of both carotid arteries simultaneously B. Auscultation of the arteries for bruits with the bell of the stethoscope C. Palpation of the arteries for murmurs bilaterally D. Auscultation of the arteries for thrills with the diaphragm of the stethoscope

B. The bell of the stethoscope is more effective than the diaphragm in transmitting blowing or swishing sounds such as those from turbulence in blood vessels.

A nurse is caring for a client who is producing large amounts of urine. The nurse should document this finding as which of the following? A. Retention B. Oliguria C. Diuresis D. Dysuria

C. Diuresis or polyuria is the excretion of a high volume of urine. It has many causes, including metabolic and hormonal imbalances and diuretic therapy for treating renal, cardiovascular, or pulmonary disorders.

A nurse is reviewing the laboratory results for a client who has a non-healing wound. Would cultures have identified vancomycin-resistant enterococci (VRE). Which of the following types of precautions should the nurse initiate? A. Airborne B. Droplet C. Contact D. Protective

C. Contact precautions are a type of transmission-based precaution for clients who have an infection with an organism such as VRE, which spreads either by direct or indirect contact.

A nurse is reinforcing teaching with a middle adult client about disease prevention and health maintenance. Which of the following diagnostic tests should the nurse recommend as part of routine health screening for women 50 to 64 years of age? A. Annual Papanicolaou (Pap) tests B. Mammogram every 2 years C. Eye examination every 2 years D. Annual colonoscopy

C. This screening is essential not only for monitoring vision but also for checking for glaucoma. The client should have annual eye examinations from the age of 65 onward.

The 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."

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 reinforcing teaching with a client about lifestyle changes to manage a chronic illness. Which of the following strategies should the nurse use first to help the client make a commitment to these lifestyle changes? A. Identify the risks of non-adherence B. Schedule learning sessions to demonstrate the psychomotor skills the client will need C. Provide clearly written easy-to-understand materials D. Assist the client to identify ways that these changes will result in positive personal outcomes

D. According to evidence-based practice, the motivation to change must precede taking steps to make the change. Therefore, assisting clients to identify ways that the changes will promote positive outcomes should precede other educational strategies about making the changes. The client should first see how the changes directly affect his/her life, thus enhancing the motivation to make the changes.

A new resident provider asks the nurse for an access code to review a clients online record. The resident is not scheduled to attend the Facility's orientation computer class until next week. Which of the following actions should the nurse take? A. Explain that sharing access codes is against policy and refer the resident to the supervisor B. Access the client's online data and monitor the resident during usage. C. Access the online client data system and allow the resident to locate the client's data. D. Ask the client to give permission for the resident to access the medical records.

A. Sharing codes is a breach of federal guidelines for data security and client confidentiality.

During a client care staff meeting, A charge nurse discusses potential problems with data security that affect confidential client information. Which of the following environments should the charge nurse identify as an acceptable area for discussing client information? A. In the unit medication room B. Outside the door of a client's room C. In the cafeteria during break D. In the hallway near the nurses' station

A. Nurses should only communicate clients' information in areas where no one else can overhear the discussion. A unit medication room is a nonpublic area where nurses can privately discuss information that pertains to the client's care.

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. Assist the client in changing positions D. Offer the client a heat or cold pack to place on painful areas

A. Using the nursing process, the nurse should first collect data to determine the reason for the client's refusal of opioid pain medication.

A nurse is reinforcing teaching with a client about how to remove a soiled dressing. Which of the following statements by the client indicates an understanding of the teaching? A. "I'll wear nonsterile gloves." B. "I'll use adhesive remover each time." C. "I'll take my pain pill after I change the dressing." D. "I'll fold the dressing with the soiled surface facing outward."

A. Wearing gloves prevents the spread of microorganisms outside of the dressings and onto the client's hands. The gloves the client uses can be clear and do not need to be sterile, unless the provider specifically prescribes sterile gloves for dressing changes.

A nurse is preparing to irrigate a client's wound. Which of the following actions should the nurse take? A. Use a 10 mL syringe. B. Attach a 22-gauge catheter to the syringe. C. Warm the irrigating solution to 37 degrees Celsius (98.6 F). D. Administer an analgesic 10 minutes before the irrigation.

C. The nurse should prepare about 200 mL of irrigating solution and warm it to body temperature to minimize the client's discomfort and vascular constriction.