Fundamentals Exam 3

A health care provider orders an infusion of 250 mL of NS in 100 minutes. The set is 20 gtt/ml What is the flow rate?

50 gtt/min

In which client should the nurse prioritize assessments for respiratory depression?

A client taking opioids for cancer pain

A client's EHR states that two medications are due at the same time, both of which are available in vials and are to be administered by injection. What is the nurse's most appropriate action?

Determine the compatibility of the two drugs by consulting clinical resources.

Which dietary guideline would be appropriate for the older adult homebound client with advanced respiratory disease who informs the nurse that she has no energy to eat?

Eat smaller meals that are high in protein.

An older adult client tells his home care nurse that he doesn't seem to sleep as well as he used to. The nurse is aware that the sleep changes that occur in the older adult client which cause a less restful sleep include:

a decrease in the deep sleep stage of the sleep cycle.

Which client is at a greater risk for fluid volume deficit related to the loss of total body fluid and extracellular fluid?

an infant age 4 months

A client's most recent blood work indicates a K+ level of 7.2 mEq/L (7.2 mmol/L), a finding that constitutes hyperkalemia. For what signs and symptoms should the nurse vigilantly monitor

cardiac irregularities

Edema

extracellular fluid volume excess

A client is admitted to the nursing unit from the emergency department with a diagnosis of hypokalemia. Laboratory results show a serum potassium of 3.2 mEq/l (3.2 mmol/l). For what set of manifestations should the nurse be alert?

muscle weakness, fatigue, and arrythmias

In Stage 4 sleep, the:

pulse rate is low

A sensory deficit that may arise from the client's eyes being bandaged after eye surgery can result in:

total disorientation.

A nurse is explaining the use of sleep hygiene to a client experiencing insomnia. Which statement accurately describes recommended guidelines for the use of this technique? Select all that apply

Eat a light meal before bedtime. Take a warm bath before bedtime.

A student nurse is preparing a presentation on sleep hygiene practices. What information should the nurse include? Select all that apply.

Eliminate caffeine intake 6 hours prior to bedtime. Do not watch television in bed. Use blackout or other types of curtains/blinds to keep the room as dark as possible.

The nurse is caring for a client who reports insomnia. The client has recently moved from an area near a fire station in the inner city to the country. Which recommendation will the nurse make to facilitate sleep?

Find a phone app that plays sounds of the city.

Older adult clients easily become confused when admitted to the hospital. The nurse understands that there are various reasons for this. Which reason further supports this phenomenon?

Hospital procedures and its environment may trigger sensory overstimulation.

The nurse is attempting to wake a client from sleep and is having a difficult time arousing them. What stage of sleep does the nurse identify the client is experiencing?

REM sleep

A client has been receiving intravenous (IV) fluids that contain potassium. The IV site is red and there is a red streak along the vein that is painful to the client. What is the priority nursing action?

Remove the IV

The nurse is caring for a client receiving intravenous fluids through a peripheral intravenous catheter (IV). On rounds, the nurse notes that the client's IV site and arm are swollen and cool to the touch. Based on these assessment findings, what will the nurse do next?

Remove the peripheral intravenous catheter

During the nurse's morning assessment of a client with a diagnosis of dementia, the client states that the year is 1949 and believing to be in a hotel. How should the nurse best respond to this client's disorientation?

Reorient the client to place and time

When caring for a client who is on intravenous therapy, the nurse observes that the client has developed redness, warmth, and discomfort along the vein. Which intervention should the nurse perform for this complication?

Restart infusion in another vein and apply a warm compress

A nurse is volunteering at a day camp. A child is stung by a bee and develops wheezing in the upper airways. The child is experiencing:

a bronchospasm.

What is the lab test commonly used in the assessment and treatment of acid-base balance?

arterial blood gas

A client with chronic obstructive pulmonary disease has been prescribed a bronchodilator to be administered by small-volume nebulizer. The nurse should ensure that the client:

breathes through his or her mouth until all the medication has been inhaled.

A nurse is assessing a client's state of awareness and finds the client to be disoriented and restless. The client is also agitated and alternates from confusion to excessive drowsiness to extreme excitability. The nurse would document this as:

delirium

A hospitalized client refuses to eat because she fears that the kitchen personnel are poisoning her food. What is this client experiencing?

delusions

A nurse is reviewing the medication administration record. Which order does the nurse question?

diuretic administered twice daily at 9 a.m. and 9 p.m.

A nurse notes that a client admitted to a long-term care facility sleeps for an abnormally long time. After researching sleep disorders, the nurse learns that which area of this client's brain may have suffered damage?

hypothalamus

The nurse assesses a client and detects the following findings: difficulty breathing, increased respiratory and pulse rates, and pale skin with regions of cyanosis. What condition would the nurse suspect as causing these respiratory alterations?

hypoxia

Which conditions occur in clients who are experiencing the effects of sensory deprivation? Select all that apply.

inaccurate perception of sights, sounds, tastes, and smells inability to control direction of thought content difficulty with memory, problem solving, and task performance

A female client who underwent a mammogram earlier in the day is asked to have a breast ultrasound, and then informed that she demonstrates signs of breast malignancy. The nurse knows that the client is at risk for experiencing sensory:

overload.

Upon assessment of a client's peripheral intravenous site, the nurse notices the area is red and warm. The client complains of pain when the nurse gently palpates the area. These signs and symptoms are indicative of:

phlebitis

The plan of care for a client exhibiting signs of sensory deprivation includes incorporating tactile stimulation. Which nursing intervention will provide tactile stimulation?

providing a backrub with morning and evening care

A client who is blind is said to be experiencing:

sensory deficit

The primary extracellular electrolytes are:

sodium, chloride, and bicarbonate

A nurse is instructing new parents on the proper sleeping position for their newborn. In what position does the nurse instruct the parents to place the newborn?

supine

The nursing concern of sensory deprivation risk is suited for which client?

the client whose room at the end of the hallway has the door closed most of the time

The student nurse asks, "What is interstitial fluid?" What is the appropriate nursing response?

"Fluid in the tissue space between and around cells."

A nursing student is teaching a healthy adult client about adequate hydration. Which statement by the client indicates understanding of adequate hydration?

"I should drink 2,500 mL/day of fluid."

A client comes to the clinic and states to the nurse, "I am traveling overseas for a project frequently and am having a difficult time adjusting because of jet lag. What is the best response by the nurse?

"Light therapy can be beneficial and help ease the transition to a new time schedule or zone."

The nurse is administering 1,000 mL 0.9 normal saline over 10 hours (set delivers 60 gtt/1 mL). Using the formula below, the flow rate would be: gtt/min = milliliters per hour x drop factor (gtt/mL) ÷ 60 min/hr

100 gtt/min

The nurse is teaching a healthy adult client about adequate hydration. How much average daily intake does the nurse recommend?

2,500 mL/day

A health care provider orders a bolus infusion of 250 mL of normal saline to run over 1 hour. The set delivers 20 gtt/mL. What is the flow rate in gtt/min?

83 gtt/min

A client with difficulty sleeping is prescribed ramelteon. The client asks the nurse, "How does this medicine work?" Which information would the nurse include in the response?

Activates the receptors for the hormone melatonin

The nurse is assessing the vital signs of clients in a community health care facility. Which client respiratory results should the nurse report to the health care provider?

An infant with a respiratory rate of 16 bpm

A client is admitted to the hospital with shortness of breath, cyanosis and an oxygen saturation of 82% (0.82) on room air. Which action should the nurse implement first?

Apply oxygen as prescribed

A home care nurse is visiting a client with acute kidney injury who is on fluid restriction. The client tells the nurse, "I get thirsty very often. What might help?" What would the nurse include as a suggestion for this client?

Avoid salty or excessively sweet fluids.

A nurse is caring for a client newly diagnosed with sleep apnea. Which should the nurse teach the client about the most important reason why the continuous positive air pressure (CPAP) device should be used during sleep?

"The CPAP assures you get enough oxygen throughout the night.

The nurse is teaching a first-time parent about the newborn's sleep needs. The nurse would inform the parent that newborns sleep approximately how many hours in a 24 hour period?

14 to 18 hours

The community health nurse wants to identify clients who have lifestyle factors that may place them at risk for sensory disturbances. Which question will the nurse ask?

"Do you work around loud noises at work?"

A nurse is taking care of a client who requests acetaminophen to help with a headache. The nurse checks to see if there is an order for acetaminophen and notices that the client is able to have 650 mg every 4 hours as needed for pain. What type of order is this considered?

PRN order

The nurse is assessing an adult client who has presented to the emergency department with general weakness. The nurse reviews the client's health record to find there is no history of underlying health conditions. The nurse will begin preparing for the insertion of a peripheral intravenous line if which assessment finding(s) are present? Select all that apply.

The client reports using laxative substances daily. The client has been vomiting for several days. The client has a serum potassium level of 2.0 mEq/l (2.0 mmol/l). The client has severe iron-deficiency anemia.

The nurse is assessing a newborn in the nursery. The nurse notes the infant has episodes in which breathing ceased for 20 seconds on 2 occasions. The nurse correctly recognizes this condition as:

apnea

The nurse is caring for a client with chronic obstructive pulmonary disease (COPD) who expresses concerns about the ability to breathe easier. The nurse will suggest which position to help alleviate the client's dyspnea?

high fowler's

A nurse is reviewing the client's serum electrolyte levels which are as follows:Sodium: 138 mEq/L (138 mmol/L)Potassium: 3.2 mEq/L (3.2 mmol/L)Calcium: 10.0 mg/dL (2.5 mmol/L)Magnesium: 2.0 mEq/L (1.0 mmol/L)Chloride: 100 mEq/L (100 mmol/L)Phosphate: 4.5 mg/dL (2.6 mEq/L)

hypokalemia

A 50-year-old client with hypertension is being treated with a diuretic. The client reports muscle weakness and falls easily. The nurse should assess which electrolyte?

potassium

A client has just been told that he has lung cancer. The health care provider then describes several potential courses of treatment to the client. When the health care provider leaves the room, the client asks the nurse, "What did he just say?" The nurse understands that the client is experiencing:

sensory overload.

The nurse is caring for a client who is receiving a prescribed intravenous (IV) infusion of an antibiotic to treat an infection. The client asks the nurse, "Can I just take a pill?" What is the best response by the nurse?

"An IV infusion maintains a therapeutic level of the medication in your blood."

A client who uses portable home oxygen states, "I still like to smoke cigarettes every now and then." What is the appropriate nursing response?

"You should never smoke when oxygen is in use."

A client has voiced concerns about her inability to fall asleep. When reviewing her history, what information would the nurse expect to find? Select all that apply.

smokes 1 pack of cigarettes daily drinks coffee with all meals history of hyperthyroidism