Fundamentals

Which of the follwoing food items should the nurse recommend as a good source of complete protein?

cheddar cheese

A nurse is assessing an older adult client's risk for falls. Which of the following assessments should the nurse use to identify the client's safety needs?

-pupil clarity -Visual fields -Visual acuity

A nurse is providing care to four clients. Which situation requires the nurse to complete an incident report?

A client who has an IV infusion pump receives an additional 250 mL of IV fluid (report IV malfunction to assist in compiling information for risk management to determine actions to take to further prevent similar incidents)

A nurse is caring for a client who has a sodium level of 125 mEq/L. Which of the following findings should the nurse expect?

Abdominal cramping Tachycardia is manifestation of hypovolemia along with hyponatremia

A nurse has just inserted an NG tube for a client. Which of the following assessment findings should the nurse expect to confirm correct tube placement?

An x-ray shows the end of the tube above the pylorus

A nurse is admitting a client who is having an exacerbation of heart failure. In planning this client's care, when should the nurse initiate discharge planning?

During the admission process

A nurse is initiating a protective environment for a client who has had an allogenic stem cell transplant. Which of the following precautions should the nurse plan for this client?

Make sure the client wears a mask when outside her room if there is construction in the earea

A nurse is caring for a patient with tuberculosis. Which of the following actions should the nurse take? (Select all that apply)

Place the client in a room with a negative pressure airflow (Meets requirements of airbone precautions) Wear gloves when assisting the client with oral care (Wear gloves whenever hands make contact with bodily fluids, meets requirements of standard precautions) The nurse should wear an N95 respirator during client care (to meet requirements of airborne precautions) Use antimicrobial hand sanitizer for routine hand hygiene (nurse should also wash her hands with soap and water when hands have visible soiling)

A nurse is planning to insert a peripheral IV catheter for an older adult client. Which action should the nurse plan to take?

Place the client's arm in a dependent position (Because the veins will dilate due to gravity)

A nurse is caring for a client who has an NG tube and is receiving intermittent feedings through an open system. Which action should the nurse take first?

Tell the client to keep the head of the bed elevated at least 30 degrees (prevent aspiration of enteral formula, keep head of bed elevated to prevent reflux of the formula backward into the esophagus)

A nurse is teaching a client and his family how to care for the client's tracheostomy at home. Which of the following instructions should the nurse include in the teaching?

Use tracheostomy covers when outdoors

A nurse is admitting a client who has varicella. Which type of transmission precautions should the nurse initiate?

Airborne

A nurse is preparing to insert an IV catheter into a client's arm prior to initiating IV fluid therpay. Which of the following interventions should the nurse implement to prevent infection?

thread the IV catheter so that the hub rests at the insertion site

A nurse is reviewing the medical records of a client who has a pressure ulcer. Which of the following findings should the nurse expect?

Albumin level of 3 g/dL indicates protein deficiency, placing the client at risk for pressure ulcer formation and poor wound healing braden scale of less than 18 indicates pressure ulcer

a nurse in a surgical suite notes documentation on a client's medical record that he has a latex allergy. In preparation for the client's procedure, which of the following precautions should the nurse take?

Wrap monitoring cords with stockinette and tape them in place -Many monitoring devices and cords contain latex. The nurse should prevent any contact of these cords and devices with the client's skin by covering them with a non latex barrier material, such as stockinette, and using non latex tape to secure them

A nurse is on a medical unit preparing to discharge a client to home. Which of the following actions should the nurse take as part of the medication reconciliation process?

Compare prescriptions w/ medications the client received during hospitalization

A nurse is caring for a client who has pharyngeal diptheria. Which of the following types of transmission precautions should the nurse initiate?

Droplet

A nurse is caring for a client who is expressing anger over his diagnosis of colorectal cancer. Which of the following actions should the nurse take?

Reassure the client that this is an expected response to grief During the anger stage of the client's psychosocial adaptation to illness, the nurse should support the client and ensure him that this is an expected reaction to a cancer diagnosis