Fundamentals Exam 2
condom catheter
A catheter that has an attachment on the end that fits onto the penis, also called an external or ''Texas'' catheter. Often times used for clients who have paraplegia at night.
a nurse is obtaining a health history from a client. which of the following findings should the nurse identify as a risk factor for heart disease?
A diet high in saturated fats a history of smoking for 25 yrs a sedentary lifestyle
a nurse is reviewing documentation principles with a group of newly hired AP. Which of the following information should the nurse include?
A nurse who delegates a task to an AP will review the charting for that task. RN and LPNs have authority to delegate certain tasks in certain situations. Part of delegation includes following up to ensure that the task was documented correctly in the clients record.
a nurse is discussing problem-oriented medical records with a group of newly licensed nurses. which of the following information should the nurse include?
A problem-oriented medical record uses progress notes, which promotes information sharing among members of the interdisciplinary team.
source-oriented medical record
A separate area for information from various sources, including testing, nurses' notes, and progress notes
a nurse at an urgent care clinic is auscultating the lungs of a client who reports a cough and sob. which of the following steps of the nursing process is the nurse using?
Assessment. The nurse should identify auscultating a clients lungs as being part of the assessment step of the nursing process because the nurse is collecting data from the client. Auscultating the clients lung sounds is part of the physical assessment.
A nurse has performed pre-operative care on a client and is transferring the client to the surgical holding area when the client states, "I have changed my mind; I do not want to have this surgery." which of the following ethical principles is the client using?
Autonomy. Autonomy involves the client's right to make decisions about their care, including the right to refuse treatment if they choose. This ethical principle refers to a client's freedom.
A charge nurse is planning to discuss factors that can influence the clinical decision-making process in client care with a newly licensed nurse. Which of the following factors should the charge nurse include? Select all that apply.
Available resources, awareness of client status, and support from other staff Resources are factors that can influence the decision-making process, which is used as the framework for developing the plan of care. The nurses awareness of the clients status is a factor that can influence the decision-making process The availability of support from other staff is a factor that can influence
a nurse is assessing a client who has COPD. The nurse should identify that which of the following is an expected finding?
Clubbing of the fingers
a nurse is caring for a client who reports occasionally having dark, tea-colored urine at home. the nurse identifies that which of the following activities can contribute to this finding?
Consuming alchohol Dark urine is a sign of urine concentration and can be a sign of dehydration. Certain beverages, however, can increase urine production. alcohol and caffeinated beverages such as cola, coffee, and tea all increase urine production and can be dehydrating if not balanced with water consumption.
a nurse is preparing to assist with feeding a client who is at risk for aspiration. which of the following actions should the nurse take?
Cut the clients food into small bites.
a nurse is caring for a client with suspected dehydration. for which of the following findings should the nurse monitor this client?
Dry mucous membranes dehydration is a decrease in fluid volume leading to a negative fluid balance. dry mucous membranes or a dry mouth are manifestations of dehydration.
a nurse is preparing to insert a nasogastric tube into a client for decompression. which of the following actions should the nurse perform first?
Ensure the client is in a sitting position. when inserting a NG tube, the nurse should first encourage the client to sit up to reduce the chance of vomiting and aspiration.
a nurse is reviewing the role of health information technology in client care with a newly licensed nurse. which of the following information should the nurse include?
Facilitates care coordination improves practice efficiencies is capable of being overridden by a nurse: a nurse is able to override health info technology in case of system, error or a risk to the client improves clinical outcomes
a nurse is discussing legal regulations regarding medical records with a newly hired AP. Which of the following information should the nurse include?
Facilities can establish their own rules for documentation methods.
a nurse is preparing to use a video-enabled device to communicate with a client who is at home. which of the following actions should the nurse plan to take?
Instruct the client to use a computer for the video conference.
a nurse is educating a client who has paraplegia about urinary catheter use. which of the following catheter types should the nurse include in the teaching to help facilitate urinary elimination for this client?
Intermittent Catheter Clients who have paraplegia will often utilize intermittent catheters in conjunction with bladder training to avoid urinary accidents due to the lack of bladder sensation from paralysis.
A nurse is caring for a client who is receiving tube feedings via PEG. Which of the following actions should the nurse implement in order to help prevent the client from aspirating?
Keep the clients head elevated to at least 30 degrees for a minimum of 1 hour after a feeding because this gives the client time to digest the feeding and helps prevent aspiration
Kussmaul Breathing
Kussmaul breathing is not an expected breathing pattern. Kussmaul breathing, respirations are rapid and deep
a nurse is performing chest percussion therapy on a client. which of the following actions should the nurse take?
Listen for a hollow sound when performing chest percussion therapy. this indicates proper technique is being used to loosen the secretions. Perform up to 4x/day
a nurse is auscultating a clients heart sounds and hears a low-pitched whooshing or blowing sound over the apex of the heart. the nurse should identify that this indicates which of the following?
Murmur A whooshing or blowing sound indicates a murmur and can be low, medium, or high-pitched
Magnesium
Muscle contraction, immune system health, nerve transmission (legumes, green veggies, seafood)
a nurse is reviewing a clients list of medications and supplements. which of the following medication classifications increases the risk of constipation?
Narcotic pain medication medications used to treat pain, such as narcotics, can slow gastric motility and increase the risk of constipation
a nurse is caring for a client who requires 1L of oxygen. which of the following oxygen delivery devices should the nurse expect to use?
Nasal Cannula The nurse should plan to use a nasal cannula because oxygen via nasal cannula can be delivered at low concentration of 1 to 4 L/M
a nurse is assessing a client who is experiencing digestive issues. which of the following findings should the nurse expect?
Nausea, abdominal pain, diarrhea, reports of bloating
a nurse is teaching a class about using smart infusion pumps to administer intravenous medications. which of the following information should the nurse include?
Nurses enter client information into the smart infusion pump nurses should follow the rights of medication administration to ensure accuracy and reduce the risk for errors, which includes entering the client information into the smart infusion pump.
Urgent vs Nonurgent
Priority is given to the client who has an urgent need over a client with a nonurgent need.
Vitamin C (ascorbic acid)
Promotes iron absorption, wound healing, bone formation, and immune function. (Brussels sprouts, citrus fruits, spinach, berries, tomatoes, potatoes)
A nurse is preparing to perform palpation on a client during a physical assessment. Which of the following findings is the nurse assessing during palpation?
Skin temperature, moisture, and abnormalities. The nurse can make judgements about the findings of the skin, underlying tissue, muscle, and bones by palpating the skin for temperature, moisture, texture, and other abnormalities.
a nurse is caring for a client who is receiving supplemental oxygen for hypoxia. The nurse should identify that which of the following can cause hypoxia?
Smoke Inhalation Smoke inhalation can cause a client to become hypoxic due to a lack of oxygen and ventilation.
a nurse is reviewing the medical history of a client who has heart disease and a narrowed valve. which of the following findings should the nurse expect?
Stenosis Stenosis is a narrowing or stiffening of the heart valve that causes back flow of the blood.
A nurse is performing auscultation during a client's physical assessment. Which of the following tools should the nurse use for this part of the assessment?
Stethoscope
a nurse is planning to measure the cardiac output of a client who had a myocardial infarction. which of the following data should the nurse use to calculate the clients cardiac output?
Stroke volume Cardiac output is a measurement of the volume of blood pumped by the left ventricle in 1 min. Cardiac output is calculated by multiplying the clients heart rate by the clients stroke volume.
a nurse manager is reviewing the documentation of four newly licensed nurses. which of the following medication entires should the nurse identify as being written correctly?
Sythroid 100 mg PO every morning ac
a nurse is reviewing the HIPAA regulatory rules. Which of the following rules is restricted to electronic protected health information (e-PHI)?
The Security Rule the HIPAA security rule protects confidentiality in regard to the use and disclosure of electronic protected health information.
a nurse is assessing a clients hair and notes that it is brittle. which of the following should the nurse determine about the clients nutritional intake?
The client has insufficient protein in their diet. Protein helps promote healthy hair and prevents brittle hair and hair loss.
Nonmaleficence
The ethical principle of "do no harm". This ethical principle applies to the providers involved in the client's care
Justice
The ethical principle of treating all clients fairly. this ethical principle applies to the providers involved in the clients care.
Evaluations
The final step of the nursing process is evaluation. during this step, the nurse determines if goals were achieved or not and makes revisions as needed.
a nurse is caring for a client who has a prescription for a vitamin K injection. the nurse should identify that Vitamin K is naturally produced in which of the following locations of the body?
The large intestine bacteria within the large intestine produce Vitamin K, a nutrient important for blood clotting and strong bones
large intestine
The last section of the digestive system, where water is absorbed from food and the remaining material is eliminated from the body
Auscultation
The nurse should listen to the clients bowels sounds after palpation.
Analysis
The second step of the nursing process is analysis. During this step, the nurse uses clinical judgement to identify the client's problems or risk to develop a diagnostic statement
A nurse is taking admission history for a client who is concerned about the facility using electronic documentation system. which of the following information should the nurse include as a benefit of electronic documentation?
The system alerts providers of possible actions that could cause client harm. Many electronic documentation systems contain clinical alerts, which can prompt providers regarding potential errors, such as a medication error or duplicate tests.
Planning
The third step of the nursing process is planning. During this step, the nurse sets priorities for client care and develops interventions to meet outcomes.
a nurse is caring for a group of clients who are at risk for alteration in urinary elimination. which of the following groups should the nurse identify as being at an increased risk?
Uncircumcised infants: infants prior to age 1 who have not been circumcised are at a greater risk School age children: one of the most common infections in children are UTIs Older Adults: at risk and experience urinary incontinence
a nurse is caring for a client who has a stone in the right ureter that is obstructing the flow of urine. which of the following urinary diversions should the nurse anticipate the client will need?
Ureteral Stent ureteral stent placement allows the passage of urine when a ureter is blocked from either a stone, mass, scar tissue, inflammation, or infection.
a nurse is planning care for a client who has an order for urinalysis. which of the following test should the nurse anticipate being ordered if the presence of white blood cells is detected on urinalysis?
Urine Culture this is used to evaluate the presence of bacteria and yeast. the test is commonly ordered in addition to a urinalysis to confirm the presence of bacteria in a urine revealed on the urine dipstick.
a nurse is assessing a client who has stress incontinence. which of the following findings should the nurse expect with the client?
Urine leakage following cough stress incontinence is a leakage of urine when the client engages in coughing, sneezing, laughing, or physical activity due to increased pressure on the bladder.
Iron
Vital to the transport of oxygen throughout the body. (organ meat, red meats, leafy greens, iron-fortified foods)
a nurse is caring for a client who is receiving antibiotic treatment for a urinary tract infection and is experiencing diarrhea. Which of the following should the nurse identify as a potential cause of the diarrhea?
the antibiotic eliminates the healthy gastrointestinal bacteria, allowing harmful bacteria to grow. the GI tract contains bacteria that live naturally within the body to promote health. When antibiotics are needed to treat bacterial infections, a side effect may be the loss of healthy bacteria within the GI tract. this allows other bacteria to multiply causing diarrhea.
continent cutaneous reservoir
urinary diversion consisting of a bladder that is diverted to the abdominal skin surface
A nurse is discussing atrial fibrillation with a newly licensed nurse. which of the following statements by the newly licensed nurse indicates an understanding of atrial fibrillation?
"Atrial fibrillation is caused by electrical signals outside of the SA node causing an irregular heart rate"
a nurse is discussing computerized provider order entry (CPOE) systems with staff. which of the following statements from a staff member indicates an understanding of a CPOE system?
"CPOE systems can increase the speed of care delivery" CPOE systems allow provider prescriptions to be transmitted more quickly from one department to another, which can increase the speed of care delivery for clients.
the "E" in PIE
"E" in PIE represents "evaluation"
a nurse is providing info to a client about what may happen if their urinary tract infection (UTI) is not treated. Which of the following statement by the client indicates an understanding of the information?
"I can develop a kidney infection called pyelonephritis" UTI's can result in a more serious kidney infection. client may present with severe lower back pain, fevers, nausea, vomiting or blood in their urine.
the "R" in DAR
"R" in DAR, represents "response"
A nurse is reviewing the documentation of a newly licensed nurse. Which of the following entires should the nurse identify as meeting the American Nurses Association (ANA) standards for documentation?
"The client vomited 240 mL of clear emesis but denies pain or nausea" According to ANA standards, documentation should be factual and complete. Information charted here includes measurements, visual observations, and client data.
a nurse is caring for a client who has a new prescription for a clear liquid diet. the client ask the nurse "how long will I have to be on this diet?" which of the following responses should the nurse make?
"You should be on this diet no more than a few days" clear liquid diet should be limited to a few days because this type of diet has inadequate nutritional value.
a nurse is caring for a client who states, "I feel like I don't have to eat a varied diet when I take my multivitamin" which of the following responses should the nurse make?
"a multivitamin should not be used in place of a nutritious diet" this client should eat a varied, nutritious diet daily even while taking a multivitamin.
a nurse is caring for a client who states, "I only eat a diet high in protein and carbohydrates". Which of the following responses should the nurse make?
"a nutritious diet should include carbohydrates, protein, fiber, and healthy fats."
a nurse is providing teaching for a client who has a new prescription for a continuous positive airway pressure (CPAP) machine to treat obstructive sleep apnea. which of the following statements should the nurse include?
"cover your nose with the CPAP mask" to create a seal to treat obstructive sleep apnea. CPAP is used for obstructive sleep apnea to keep the upper airway open and increase a clients oxygenation.
A nurse is reviewing the concept of critical thinking with a newly licensed nurse. which of the following statement should the nurse make?
"critical thinking is the foundation for clinical decision making" Critical thinking is considered a higher order of thinking that is the foundation for clinical decision making. it is a critical component of nursing care and is used in each step of the nursing process to enhance client care.
a nurse is caring for a client who states, "I have been getting a lot of cavities lately, but I don't know what is causing them." Which of the following responses should the nurse make?
"drinking sugary beverages can make you prone to cavities"
a nurse is reviewing the use of electronic documentation with a newly licensed nurse. Which of the following statements should the nurse make?
"electronic documentation provides evidence of care provided" documentation provides evidence of care provided. Complete, accurate, and timely documentation promotes continuity and quality of client care.
a nurse is teaching a newly licensed nurse about pulmonary function tests. the nurse should include that which of the following is the vital capacity?
"the maximum volume of air that is expired after a minimum inspiration."
a nurse is caring for a client who has a new rx for parenteral nutrition. the client is scared and states they do not want to be on this therapy for the rest of their lives. which of the following responses should the nurse make?
"this type of nutrition can be lifelong, but it can also be temporary depending on how your nutritional needs change"
a nurse is providing teaching for a client who has a new prescription for an incentive spirometer. which of the following instructions should the nurse include?
"use the incentive spirometer every hour while awake" "hold breath for 3-5 seconds" "use at least 10 times each sessions to promote lung expansion"
a nurse is caring for a female client who has a prescription for a clean catch urine specimen. Which of the following statements by the client demonstrates an understanding of how to provide a urine specimen?
'I need to wipe from front to back with a sanitary wipe" female clients should be instructed to use sanitary wipes to clean the genital area from front to back.
Chest Tube
-Continuous bubling in the water seal champers indicates an air leak. If this is observed, the nurse should attempt to located the source of the air leak and intervene accordingly (tighten the connections, replace drainage system)
a nurse is explaining the sequence of electrical conduction int he heart to a newly licensed nurse. What is the correct sequence of the transmission of electrical impulses?
1. SA Node 2. AV Node 3. Bundle of His 4. Right and left bundle branches 5. Purkinje Fibers
a nurse is teaching a client who has an abdominal incision about coughing and deep breathing. in which order should the nurse instruct the client to perform the following steps?
1. Take a deep breath (promotes lung expansion) 2. hold your breath for several seconds (promote lung expansion) 3. exhale slowly (promote alveolar inflation) 4. brace the incision with a pillow and try to cough deeply (comfort and support to try and clear secretions)
Enema administration
1.Not sterile, gloves, privacy, warmed solution as ordered, adult 750-1000 ml 2.Assess for abdominal distention, bowel sounds *3.Left side, sim's position (follow natural curve of colon), insert lubricated tip, adult 3-4 inches 4.Open clamp and allow to flow slowly, raise to appropriate height, can cause cramping if flow rate too rapid 5.If order, "enemas until clear", repeat until fluid passed is clear, up to 3 total
How many ml of fluid per day?
2000 mL
a nurse is helping a client calculate how many net carbohydrates they consumed in their last meal. the clients food had a total of 72 carbohydrates and 9 g of fiber. how many net carbs did the client consume?
72 g - 9 g = 63 net carbs
a nurse is suctioning a clients tracheostomy using an open system. Which of the following actions should the nurse take to reduce risk of hypoxia?
Administer 100% oxygen before the procedure suction for 10 to 15 seconds apply intermittent suction when withdrawing the catheter sterile technique should be used to reduce risk for infection
a nurse is assisting with teaching a newly licensed nurse about using barcode technology in client care. the nurse should include that barcode technology is used to reduce errors during which of the following phases of the medication process?
Administering the use of barcode technology is used during the administering phase of the medication process. the nurse should scan the clients identification band barcode before scanning the barcode on the medication to alert the nurse to any possible errors before they occur.
a nurse is discussing ventilation and perfusion with a newly licensed nurse. the nurse should include in the discussion that the exchange of oxygen and carbon dioxide occurs at which of the following locations?
Alveoli The alveoli are air-filled sacs where the exchange of oxygen and carbon dioxide occurs.
Inspiratory Reserve Volume (IRV)
Amount of additional air that can be inspired after a regular inspiration
Apnea
Apnea is not an expected breathing patter; it is the absence of respirations.
A nurse in the ED has received report on a child who has a laceration to the right calf. Which of the following steps of the nursing process should the nurse perform first?
Assessment. The first step of the nursing process is assessment. During this step, the nurse gathers information by performing a physical exam, interviewing a client, and observing a client.
Vitamin K
Blood clotting and bone health (green leafy veggies, spinach, liver, butter, kale, parsley)
Vitamin D
Bone and teeth development, absorption and metabolism of calcium and phosphorus. (fish oil, milk, eggs, dairy products, *sun light)
a nurse is preparing to administer morphine 15 mg PO every 4 hr PRN pain for a client who has a new Rx. which of the following routes should the nurse plan to administer the med?
By mouth
Cheyenne-Stokes breathing
CS is not an expected breathing pattern. In CS breathing, the client has periods of apnea, then deep and rapid breathing, followed by slower breathing.
Aerosol Mask
Can be used to administer medications, such as bronchodilators.
Diabetic Ketoacidosis (DKA)
Can cause a client to hyperventilate, blowing off excess carbon dioxide and causing acidosis
A newly licensed nurse is orienting to a facility documentation system. the facility requires staff to only document variations from an expected set of findings when performing a physical assessment. the nurse should identify this system as which of the following documentation methods?
Charting by Exception (CBE) CBE, the only chart unexpected findings. this can be done on a flowsheet or through narrative notes
a nurse is caring for a client who has a history of IBS and reports that their last bowel movement was 5 days ago. the nurse should identify this as which of the following types of altered elimination pattern?
Constipation slows the production of stool. it can result in dry, hard-to-pass bowel movements and gives a sensation of incomplete emptying or passing of stool.
a nurse is caring for a client who has left-sided heart failure. which of the following findings should the nurse expect?
Crackles in the lungs Left sided heart failure causes the blood to back up into the pulmonary circulation, causing crackles in the lungs
a nurse is completing a medication reconciliation on a newly admitted client. which of the following info should the nurse include?
Current prescribed medications nutritional supplements the client takes over the counter medications the client uses
a nurse is caring for a client who has been wheezing. the nurse asks an AP to use a stethoscope and listen to the clients lung sounds to determine if their wheezing has improved. this is an example of which of the following concepts?
Delegation of the wrong task.
Nonrebreather Mask
Delivers oxygen at high concentrations of 10 to 15 L/min
a nurse is preparing to collect a urine sample for urinalysis using a reagent strip. the nurse should identify the the reagent strip can detect substance that are consistent with which of the following conditions?
Diabetes Urine concentration, protein, glucose, ketones, bilirubin, leukocytes, nitrates, and blood can also be tested with a urinalysis
a nurse is preparing to perform a physical examination on a client. Which of the following interventions should the nurse perform to ensure client privacy?
Do not expose any more of the clients body than required at a time.
a nurse is caring for a client who is receiving IV therapy via a peripheral catheter. The nurse should identify that which of the following findings is an indication of infiltration?
Edema at the infusion site
a nurse is planning care for a client who reports blood in their stool. which of the following tests should the nurse anticipate the provider ordering?
Fecal Occult Blood Test
Potassium
Fluid balance, muscle function, and nerve transmission (bananas, avocados, potatoes, tomatoes, fruit, legumes, and whole grains)
Sodium
Fluid balance, nerve transmission, muscle contraction (salt, soy sauce, processed foods, meats)
A nurse is preparing to irrigate a client's leg wound. which of the following pieces of PPE should the nurse wear while performing this tasks?
Googles, gloves, and gown
A nurse is assisting with teaching a class about HIPAA. which of the following information should the nurse include?
HIPAA protects the unauthorized release of clients protected health information The loss of a providers cell phone that contains a clients protected health information is considered a data breach A breach in HIPAA should be reported within 60 days after the breach is discovered.
A nurse is planning care for a client who has a new colostomy. Which of the following complications should the nurse plan to monitor for?
Hernia complications of fecal diversions include hernia, electrolyte imbalance, blockage, prolapse, diarrhea, and infection.
a nurse is caring for a client who has constipation. which of the following diets should the nurse encourage the client to follow?
High fiber
a nurse is reviewing the med record of a client who has persistent diarrhea. which of the following findings should the nurse identify as risk factors?
History of IBS Consumes large amounts of dairy in their diet Currently taking antibiotics for an infection
a charge nurse is discussing health records with a newly licensed nurse. Which of the following information should the nurse identify as a component of a health record?
Immunization Data The nurse should include that a health record contains any info that could influence a clients health, such as immunization status. Other information includes medications, allergies, and demographic data.
a nurse is assisting a client with ambulating around the nurses' station. Which of the following steps of the nursing process is the nurse performing?
Implementation. During the implementation step, the nurse carries out the interventions develop in the plan of care, which will assist the nurse and other members of the health care team to monitor the clients progress. Implementation is when the nurse puts the plan of care into action.
A charge nurse is preparing to discuss critical thinking skills with a group of newly licensed nurses. Which of the following skills should the nurse plan to include in the discussion? Select all that apply
Inference, creativity, and inductive reasoning Inference is a skill that is associated with critical thinking that the nurse can use as part of higher-level thinking Creativity is a skill that is associated with critical thinking. the nurse can use creativity as a part of higher-level thinking to critically analyze problems and develop solutions. Inductive reasoning is a skill that is associated with critical thinking that the nurse can use as a part of higher-level thinking
A nurse has just received report on a newly admitted client who reports abdominal tenderness in the lower right quadrant. Which of the following is the first step the nurse should perform during the abdominal assessment?
Inspection
Jugular vein distension
Is an expected finding for a client who has fluid overload
a nurse is caring for an older adult client who is experiencing urinary leakage. which of the following is an expected age-related change that can contribute to this occurrence?
Loss of bladder tone loss of bladder tone can lead to issues such as urinary leakage, incontinence, or retention.
A nurse is reviewing documentation guidelines with a newly licensed nurse. which of the following abbreviations as being on the Joint Commission's Do Not Use List? Select all that apply
MSO4 - this abbreviation for morphine should be written out as "morphine sulfate" qhs - this abbreviation should be written "nightly" IU - this word "unit: should be written out in full
a nurse is discussing macronutrients with a client. which of the following statements should the nurse make?
Macronutrients include carbohydrates, proteins, and fats, which make up the majority of a persons diet. This provides the body with energy to function and are the building blocks of the diet.
A nurse is performing a pre-admission assessment on a client and employs the use of nonverbal and verbal communication. Which of the following actions demonstrates the use of a nonverbal communication technique by the nurse?
Maintain a fair distance between self and client. The nurse should maintain a personal space of about an arm's length (46 to 102 cm, or 18 to 40 in) when communicating with the client. This is a form of nonverbal communication.
a nurse is preparing to measure a nasogastric tube for insertion. the nurse recalls that the clients xyphoid process should be used as the last place of measurement. which of the following landmarks should the nurse measure before the xyphoid process?
Measure from the tip of the nose to the earlobe, then from the earlobe to the xyphoid process. This would give an accurate measurement for tub insertion, allowing appropriate tube placement.
a nurse is caring for a client who has a chest tube. which of the following actions should the nurse take?
Monitor the client for subcutaneous emphysema which can indicate a leak or blockage of the system.
a nurse is caring for a client who has a history of asthma and wheezing. which of the following actions should the nurse take?
Obtain oxygen saturation The greatest risk to this client is injury from hypoxia; therefore, the first action is to obtain clients oxygen saturation. this will assist in deterring the next intervention
a nurse is reviewing a clients medical record and notes that their BMI is 25.5. how should the nurse interpret this finding?
Overweight
a nurse is assessing a client who has an indwelling urinary catheter and determines that the catheter is in place and functioning properly. The nurse should expect which of the following findings?
Pale yellow, clear urine. This determines client is healthy
A nurse is performing a physical assessment of a client who has reported abdominal tenderness. Which of the following actions should the nurse take?
Palpate the tender areas of abdomen last. The client reported abdominal tenderness, so the nurse should palpate tender areas last because tense muscles make the assessment more difficult for the client.
A nurse is preparing to assess a newly admitted client. Which of the following pieces of equipment does the nurse need to begin the inspection part of the physical examination? (select all that apply)
Pen light, tape measure, and tongue depressor
a nurse is caring for a client who has a colostomy and does not wear a colostomy pouch. which of the following actions should the nurse anticipate performing on this client to maintain expected bowel function>
Perform colostomy irrigation Colostomy irrigation acts as a type of bowel training to help prevent passage of stool at other times and reduces the clients needs to wear a colostomy pouch.
A nurse is preparing an in-service about HIPAA. Which of the following info should the nurse plan to include?
Personnel can be terminated for breaching a clients confidentiality
Nephrostomy tube
Plastic tube used to drain the kidney through a hole in the back into a urine collection bag.
a nurse is providing teaching for a client who has a prescription for home oxygen. which of the following instructions should the nurse include?
Post a "no smoking" sign inside the house to reduce risk of fire Attach oxygen containers to a fixed object to keep them from falling over Notify the fire dept that oxygen is used in the home to ensure client safety in case of power outage or a fire oxygen tubing should be no longer than 50 ft in length to reduce fall risk oxygen containers should not be stored in a closed space, such as closet to reduce risk of injury
Calcium
Proper function and structure of teeth and bones, muscle function, blood pressure regulation. (milk, milk products, broccoli, leafy greens, legumes)
a nurse is caring for a non-diabetic client who has a new prescription for a fasting blood glucose check. The nurse checks the clients blood glucose and it is 67 mg/dL. which of the following actions should the nurse take next?
Provide the client with a 15-g carbohydrate snack to up their blood glucose level to the expected reference range. The clients glucose level is low, less than 70 mg means the client is hypoglycemic
a nurse is caring for a client who is crying and appears upset after receiving news that they will need to have a surgical procedure. which of the following actions should the nurse take to display empathy towards the client?
Put themselves in the clients situation to understand the clients anxiety.
A charge nurse is reviewing SOAP documentation with a group of newly licensed nurses. Which of the following chart entries should the nurse include as an example of objective data?
Rebound tenderness noted in RLQ of the abdomen Objective data is information the nurse gathers when collecting data about the client, such as through physical assessment or diagnostic testing.
A nurse is completing documentation in a clients medical record. Which of the following actions should the nurse take?
Record the clients most recent assessment results. The nurse should include
a charge nurse is reviewing characteristics of electronic documentation with staff at a providers office. which of the following characteristics should the charge nurse plan to include?
Reduces medical errors. the charge nurse should inform the staff that electronic documentation systems can help reduce medical errors. Makes client medical history more easily available. The charge nurse should include that electronic records help to make client information readily available Increases accuracy of coding procedures. The charge nurse should inform the staff that electronic records can lead to more reliable coding and billing for client conditions.
Fidelity
Refers to faithfulness. There is a responsibility for nurses to honor promises to the client, the institution, and themselves.
A nurse has just received report on a newly admitted client who speaks a different language than the nurse. Which of the following actions should the nurse take to assist with effective communication with the client during the initial assessment process?
Request assistance from an interpreter during the assessment.
A nurse is assessing a client who is receiving oxygen therapy. the nurse should identify that which of the following findings can indicate oxygen toxicity?
Ringing in the ears as well as headache, disorientation, and muscle twitching can indicate oxygen toxicity Blurred/double vision shivering hyperventilation and dyspnea
a nurse is caring for a client who requires 7L of oxygen to maintain oxygen saturation. Which of the following oxygen delivery devices should the nurse expect to use?
Simple face mask, it delivers a medium concentration of 5-8 L/min
A nurse is performing an assessment on a client. the client states, "I have a dry cough every morning when I wake up." which of the following is the type of data the nurse is collecting?
Subjective. Subjective data includes feelings and concerns from the clients POV. the reason why the client sought medical care is usually considered objective data. this type of data along with objective data, provides the nurse with info that will be reported to the provider.
a nurse is caring for a client who has atelectasis. the nurse should identify that which of the following substances is required to keep the clients alveoli from collapsing and causing atelectasis?
Surfactant Surfactant is a lubricant required to keep alveoli in the lungs from collapsing during exhalation. a lack of surfactant cause result in atelectasis.
a nurse is discussing the history of electronic health records (EHRs) during a staff in-service. The nurse should identify that which of the following agencies advocated for nationwide use of EHRs?
The Institute of Medicine The nurse should identify that the Institute of Medicine is the agency that recommended nationwide use of EHRs in 1997. The recommendation was driven by the belief that it would increase safety in client health care.
A nurse is assisting with teaching a client about remote patient monitoring (RPM) devices. Which of the following information should the nurse include?
The transfer of data is accomplished using wireless devices. Clients can participate in their health by using RPM A clients heart rhythm can be transferred using RPM.
a nurse is providing post op instructions for a client who had kidney stone removal and placement of a nephrostomy tube. which of the following statements by the client indicates an understanding of the instructions?
The tube is only temporary this type of diversion is usually temporary and is removed once the kidney has healed.
a nurse is reviewing the primary function of the urinary tract with a group of newly licensed nurses. which of the following information should the nurse include?
The urinary tract eliminates waste and excess fluid from the body.
Per rectum
Through the rectum; a medication delivery route.
Inspection
Using the nursing process, the nurse should first inspect the client's abdomen and observe for symmetry between the right and left side of the body. The nurse should note the presence of the contours and any abnormalities with the skin, rashes, deformities, or masses.
continent ileostomy
a bowel diversion system that is accessed with a catheter so the contents in the pouch can be drained
a nurse is teaching a newly licensed nurse about urinary retention. which of the following clients should the nurse include as having an increased risk for this condition?
a client who has an enlarged prostate.
a nurse is planning care for a group of clients on a cardiopulmonary unit. which of the following clients should the nurse plan to see first?
a client who reports dyspnea when walking to the bathroom.
prolapsed bladder
a hernia of the bladder through the vaginal wall
Systolic Murmur
a murmur is associated with a valve problem in the heart
Ileostomy
a temporary or permanent fecal diversion. if temporary, the stoma can be revered by removing the ileum from the abdominal wall and reattaching it to the colon.
Urostomy
a type of urinary diversion. A creation of an opening in the urinary tract, normally to divert urine flow away from a diseased bladder
Neobladder
a type of urinary diversion. A replacement for the missing bladder created by using about 20 inches of the small intestine
fecal incontinence
accidental bowel leakage
Gallop
additional heart sounds of S3 or S4 and are often described as sounding like "ken-tuck-y" or "ten-nes-see" a gallop can indicate aortic stenosis, hypertension, or a history of myocardial infarction
Bronchial tubes
allow air to move in and out of the lungs during ventilation
Trachea
allows air to move in and out of the lungs during ventilation
PRN
as needed
Ad lib
at liberty, as desired
a nurse is caring for a client who has renal disease and must limit potassium intake. which of the following foods should the nurse instruct the client to avoid because they are high in potassium?
bananas, dried beans, spinach, tomatoes. consuming foods high is potassium can lead to heart dysrhythmias and increase the risk of myocardial infarction for clients who have renal disease.
AC
before meals
Rapid, irregular heart rate
can indicate atrial fibrillation.
Right-sided heart failure
causes blood to back up into the systemic veins, causing lower extremity edema
a nurse is discussing clinical pathways with a newly licensed nurse. which of the following information should the nurse include?
clinical pathways use evidence-based practice guidelines for health care delivery.
Diaphragm
contracts and relaxes to facilitate ventilation
Partial rebreather mask
delivers oxygen at high concentrations of 10 to 15 L/min
Simple face mask
delivers oxygen at medium concentration of 5 to 8 L/m
problem-oriented medical record (POMR)
documentation system organized according to the person's specific health problems; includes database, problem list, plan of care, and progress notes Utilizes the SOAP format Subject, Objective, Assessment, Plan Useful in acute settings.
small intestine
food and liquid continue to mix with digestive secretions from the pancreas, liver and small intestine. It is also in absorption of water and nutrients.
a nurse is caring for clients who reports having daily constipation. which of the following information should the client regarding fiber intake?
increase daily fiber intake to alleviate constipation, eating more whole grains can promote regular bowel movements, daily fiber recommendation is 25 g per day for women and 38 g per day for men
Magnesium-containing antacids
increase gastric motility and increase the risk of diarrhea
a nurse is reviewing the impact low health literacy has for clients with a newly licensed nurse. which of the following information should the nurse include?
increase in mortality rate
Antibiotics
increase the risk of diarrhea
Red tint in Urine
indicates the presence of blood
phlebitis
inflammation of a vein
a nurse is caring for a client who has constipation and requires an enema. which of the following actions should the nurse take when administering the enema solution?
instructions the client to lie on their left side with their right leg pulled up to their chest.
J-Pouch
internal pouch formed with the ileum that collects waste
IM
intramuscular
IV
intravenous
Heart Murmur
is an expected finding for a client who has aortic stenosis
Paradoxical Breathing
is an irregular breathing pattern that can occur in a client who has fractured ribs following chest pain
Normal breathing
is regular, quiet, and shows no manifestations of discomfort
regurgitation
leaky valve that doesn't fully close and causes back flow of the blood.
a nurse is teaching a client about diagnostic urinary testing. which of the following should the nurse include in the teaching about cystometric testing?
measures bladder capacity, the pressure of the bladder during filling, and the final capacity when the urge to urinate begins
Incentive Spirometer
medical device to encourage patients to breathe deeply to prevent atelectasis and promote lung expansion.
Stenosis
narrowing, stricture
NPO
nothing by mouth
a nurse is caring for a client who routinely eats a regular diet and is scheduled to have surgery with sedation in the morning. the nurse receive a new NPO diet prescription for the client. which of the following should the nurse identify as the rationale for the providers prescription?
risk for aspiration due to the upcoming surgery with sedation. To decrease the risk of aspiration, the client should remain NPO prior to the surgery.
Calcium channel blockers
slow gastric motility and increase the risk of constipation
A nurse is documenting information in a clients chart and makes the entry "client reports abdominal pain on exertion." which of the following documentation formats describes this entry?
the "s" in SOAP S = subjective
a nurse is caring for a client following a stroke. the nurse should recognize that which of the following individuals is allowed access to the clients medical record w.o obtaining special consent from the client first? select all that apply
the admitting provider the charge nurse on the unit the client
Tidal Volume (TV)
the amount of air inspired and expired with each regular breath.
Stroke Volume
the amount of blood ejected from the ventricles during a systolic contraction
a nurse is caring for a client who is prescribed a low glycemic index diet. The client states, "I don't understand what this means" which of the following responses should the nurse make?
the glycemic index of a food relates to its ability to increase the blood glucose level you should eat foods such as whole grains, fruits, and vegetables try to limit or avoid potatoes due to their high glycemic index foods with a high glycemic index will cause your blood glucose to increase rapidly
Vital Capacity
the vital capacity is the amount of air that is forcibly expelled after a maximal inspiration
Total Lung Capacity (TLC)
the volume of air remaining in the lung after maximal inspiration
suprapubic catheter
used directly drain urine from the bladder through an access point in the lower abdomen.
24 hour urine collection
used to collect the total volume of urine excreted in 24 hours for diagnostic examination. specimen should be kept refrigerated between collections.
a nurse is assisting with teaching a class about using health information technology for client care. which of the following examples should the nurse include?
using a barcode to verify a clients medication.
Micronutrients include
vitamins and minerals that are needed in small amounts.
a nurse is caring for a client who has a high phosphorus level. which of the following instructions regarding food should the nurse provide?
you should eat white bread instead of whole-grain bread. Whole grains are high in phosphorus.
a nurse is caring for a client whose provider prescribed a heart-healthy diet. which of the following information should the nurse include for the client regarding heart-healthy diets?
you should limit saturated fats in your diet. Eat foods with whole grains limit high calorie food intake to promote adherence to new diet eat larger portions of fruits and vegetables
a nurse is evaluating a clients bladder training program. which of the following statements by the client indicates the bladder training was successful?
"I am experiencing less than one urinary accident per week" clients who have overactive bladders tend to visit the bathroom more frequently, despite the need to void, to avoid accidents. in doing so, clients inadvertently train the bladder to send messages to the brain that it is full when it is not. when clients bladder train, they reteach the bladder when to send messages to the brain, thus avoiding accidents.
a nurse is evaluating a newly licensed nurses's understanding of telephone Rx. which of the following statements by the newly licensed nurse indicates an understanding of the information?
"I can take a telephone prescription if a provider is directing a code for an unresponsive client" telephone prescriptions should be received for use only in emergency situations because there is a risk for misunderstanding details about the prescription during verbal communication. An unresponsive client is an emergency, so it is appropriate for a nurse to receive a telephone prescription in this situation.
a nurse is teaching a client about foods that can irritate the bladder. which of the following statements by the client indicates an understanding of the teaching?
"I should avoid fruits that are acidic" Bladder irritants such as alcohol, acidic fruits, chocolate, soda, and spicy foods should be avoided.
A nurse is talking with a client about their electronic health record (EHR) at the facility. Which of the following client statements indicates an understanding of EHRs?
"I will be able to track my health information"
The "I" in PIE
"I" in the acronym PIE represents "intervention".
a nurse is educating a client about a new temporary ileostomy. which of the following statements by the client indicates an understanding of the teaching?
"My ileostomy is allowing my colon time to heal from the surgery" Ileostomies can be reversed once the colon has had time to heal.
