Fundamentals Final (correct)

A nurse is caring for a client who has bilateral casts on her hands. Which of the following actions should the nurse take when assisting the client with feeding?

sit at bedside when feeding client

A client is being discharged home with oxygen therapy via a nasal cannula. Which of the following instructions should the nurse provide to the client and family?

Wear cotton clothing to avoid static electricity.

A nurse is caring for a client who is receiving a blood transfusion. The client reports flank pain and the nurse notes reddish-brown urine in the client's urinary catheter bag. The nurse recognizes these manifestations as which of the following types of transfusion reactions?

Hemolytic A hemolytic reaction occurs when the client's blood is incompatible with the donor's blood. Chills, low back pain, hypotension, and tachycardia are indications of a hemolytic transfusion reaction.

A nurse is planning to insert a nasogastric tube for a client after explaining the procedure. The client states, "You are not putting that hose down my throat." Which of the following statements should the nurse make?

I can see that this is upsetting you. The nurse is using the therapeutic communication techniques of reflecting and restating, which encourages communication by the client.

A nurse in a provider's office is reviewing the laboratory findings of a client who reports chills and aching joints. The nurse should identify which of the following findings as an indication that the client has an infection? WBC 15,000 mm3

WBC 15,000

A nurse is reviewing the correct use of a fire extinguisher with a client. Which of the following actions should the nurse direct the client to take first?

Remove the safety pin from the extinguisher.

A nurse is using the I-SBAR communication tool to provide the client's provider with information about the client. The nurse should convey the client's pain status in which portion of the report?

assessment

A nurse is caring for a client who has Clostridium difficile and is in contact isolation. Which of the following actions should the nurse take?

wear gloves when changing the client's gown.

A nurse is explaining the use of written consent forms to a newly-licensed nurse. The nurse should ensure that a written consent form has been signed by which of the following clients?

A client who has a prescription for a transfusion of packed red blood cells

A nurse on a telemetry unit is caring for a client who had a myocardial infarction. The client states "All this equipment is making me nervous." Which of the following responses should the nurse make?

All of this equipment can be frightening.

An assistive personnel (AP) is assisting a nurse with the care of a female client who has an indwelling urinary catheter. Which of the following actions by the AP indicates a need for further teaching?

Hangs the collection bag at the level of the bladder.

A nurse is teaching a client how to self-administer insulin. Which of the following actions should the nurse take to evaluate the client's understanding of the process within the psychomotor domain of learning

Have the client demonstrate the procedure.

A nurse is caring for a client, who while sitting in a chair, starts to experience a seizure. Which of the following actions should the nurse take?

Lower the client to the floor and place a pad under the client's head. To reduce the risk of injury to the client, the nurse should lower the client to the floor and place a pillow or other soft object under the client's head.

A nurse is providing oral care for a client who is unconscious. Which of the following actions should the nurse take?

Place the client in a lateral position with the head turned to the side before beginning the procedure.

A nurse is planning care for a client who is postoperative and has a history of poor nutritional intake. Which of the following actions should the nurse include in the plan of care to promote wound healing?

Provide a protein intake of 1.5g/kg of body weight per day.

A nurse is planning to perform passive range-of-motion exercises for a client. Which of the following actions should the nurse take

Repeat each joint 5 times during each session.

A nurse in the emergency department is caring for a client who has abdominal trauma. Which of the following assessment findings should the nurse identify as an indication of hypovolemic shock?

Tachycardia Due to the decrease in circulating blood volume that occurs with internal bleeding, the oxygen-carrying capacity of the blood is reduced. The body attempts to relieve the hypoxia by increasing the heart rate and cardiac output, along with increasing the respiratory rate.

A nurse is responding to a parent's question about his infant's expected physical development during the first year of life. Which of the following information should the nurse include?

A 10-month infant can pull up to a standing position. An 8 to 10-month-old infant can pull himself to a standing position.

A nurse in a provider's office is collecting information from an older adult client who reports that he has been taking acetaminophen 500 mg/day for severe joint pain. The nurse should instruct the client that large doses of acetaminophen could cause which of the following adverse effects?

Liver damage

A nurse is planning to document care provided for a client. Which of the following abbreviations should the nurse use?

PC after meals

A hospice nurse is reviewing religious practices of a group of clients with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

People who practice Judaism stay with the body of the deceased until burial.

A nurse is providing discharge teaching to a client who is recovering from lung cancer. The provider instructed the client that he could resume lower-intensity activities of daily living. Which of the following activities should the nurse recommend to the client?

Washing dishes

A nurse in a provider's office is assessing a client who has heart failure. The client has gained weight since her last visit and her ankles are edematous. Which of the following findings by the nurse is another clinical manifestation of fluid volume excess?

bounding pulse Bounding pulse is an expected finding of fluid volume excess.

nurse is teaching a client who is postoperative how to use a flow-oriented incentive spirometer. Which of the following instructions should the nurse include?

cough deeply after each use. Proper use of the incentive spirometer loosens secretions in the client's lungs. The client should cough deeply to facilitate removal of secretions from his lungs.

A nurse is caring for a client who has a fecal impaction. Before digital removal of the mass, which of the following types of enemas should the nurse plan to administer to soften the feces?

oil retention

A nurse is planning care for a client who has a single-lumen nasogastric (NG) tube for gastric decompression. Which of the following actions should the nurse include in the plan of care? (Select all that apply.)

-Provide oral hygiene frequently. -Measure the amount of drainage from the NG tube every shift. -Secure the NG tube to the client's gown.

An adolescent client in an outpatient mental health facility tells the nurse that it is hard to follow his treatment plans because his friends discourage him. Which of the following statements should the nurse make?

"Tell me more about how your friends discourage you."

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 home health nurse is planning to provide health promotion activities for a group of clients in the community. Which of the following activities is an example of the nurse promoting primary prevention?

Educating clients about the recommended immunization schedule for adults

A nurse is applying an ice bad to the ankle of a client following a sports injury. Which of the following actions should the nurse take?

Fill the bag 2/3s full with ice

A nurse is providing teaching about food choices to a client who has a prescription for a clear liquid diet. Which of the following selections by the client indicates an understanding of the teaching?

Gelatin

A nurse is caring for a client who is 48 hr postoperative following a small bowel resection. The client reports gas pains in the periumbilical area. The nurse should plan care based on which of the following factors contributing to this postoperative complication?

impaired peristalsis of the intestines

A newly licensed nurse is preparing to administer medications to a client. The nurse notes that the provider has prescribed a medication that is unfamiliar to her. Which of the following actions should the nurse take?

Consult the medication reference book available on the unit.

A nurse is reviewing the laboratory values for a client who has a positive Chvostek's sign. Which of the following laboratory findings should the nurse expect?

decreased Calcium Calcium is necessary for nerve conduction and muscle contractions. When the client's total calcium level is below 8.4 mg/dL, tetany and muscle spasms may occur. The nurse should tap the facial nerve in front of the client's ear. If facial muscle twitching follows this stimulus, it is a positive Chvostek's sign and an indication of hypocalcemia.

A nurse is called away for an emergency while conversing with a client who is concerned about his medical diagnosis. The nurse returns to the client promptly, as promised. Which of the following ethical principles is the nurse demonstrating?

fidelity

A nurse is preparing to administer an intramuscular injection to a young adult client. Which of the following injection sites is the safest for this client?

Ventrogluteal According to evidence-based practice, the ventrogluteal site is the safest injection site for all adults because it contains thick gluteal muscles and it does not contain major nerves or blood vessels.

A client who reports shortness of breath requests her nurse's help in changing positions. After repositioning the client, which of the following actions should the nurse take next?

Observe the rate, depth, and character of respirations. The nurse should apply the nursing process priority-setting framework when caring for this client. The nurse can use the nursing process to plan client care and prioritize nursing actions. Each step of the nursing process builds on the previous step, beginning with assessment or data collection. Before the nurse can formulate a plan of action, implement a nursing intervention, or notify a provider of a change in the client's status, the nurse must first collect adequate data from the client. Assessing or collecting additional data will provide the nurse with knowledge to make an appropriate decision; therefore, the first action the nurse should take is to assess the client's respiratory status.

A nurse on a surgical unit is receiving a client who had abdominal surgery from the postanesthesia care unit. Which of the following assessments should the nurse make first?

Airway

A nurse is teaching a client who has lower extremity weakness how to use a four-point crutch gait. Which of the following instructions should the nurse include in the teaching?

Bear weight on both of your legs

A nurse is performing a neurological assessment for a client. Which of the following examinations should the nurse use to check the client's balance?

Romberg

A nurse is caring for a client who has a prescription for a vest restraint. Which of the following actions should the nurse take?

Tie the restraint with a quick-release knot

A nurse is reviewing measures to prevent back injuries with assistive personnel (AP). Which of the following instructions should the nurse include?

When lifting an object, spread your feet apart to provide a wide base of support.

A nurse is caring for a client who has a terminal illness. Which of the following findings indicates that the client's death is imminent?

cold extremities

A nurse is caring for a client who is postoperative following abdominal surgery. Which of the following actions should the nurse take first after discovering that the client's wound has eviscerated?

cover the incision with a moist sterile dressing. The nurse should apply the safety and risk reduction priority-setting framework when caring for this client. This framework assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's Hierarchy of Needs, the ABC priority-setting framework, or nursing knowledge to identify which risk poses the greatest threat to the client. An open wound places the client at risk for peritonitis, and any exposed organ tissue could dry out. Therefore, covering the wound with a moist sterile dressing is the first action the nurse should take to protect the client.

A nurse is caring for a client who has acute renal failure. Which of the following assessments provides the most accurate measure of the client's fluid status?

daily weights According to the evidence-based priority-setting framework, daily weight provides important information about the client's fluid status. A gain or loss of 1 kg (2.2 lb) indicates a gain or loss of 1 liter of fluid; therefore, weighing the client daily will provide the nurse with the most accurate fluid status measurement.

A nurse is planning to assess the abdomen of a client who reports feeling bloated for several weeks. Which of the following methods of assessment should the nurse use first?

inspection According to evidence-based practice, the nurse should inspect the abdomen first by observing the contour of the abdomen, the condition of the skin, and the position of the umbilicus. Findings from this step of assessment are used by the nurse in the subsequent steps.

A nurse in a long-term care facility is admitting a client who is incontinent and smells strongly of urine. His partner, who has been caring for him at home, is embarrassed and apologizes for the smell. Which of the following responses should the nurse make?

"It must be difficult to care for someone who is confined to bed."

A nurse on a mental health unit is preparing to terminate the nurse-client relationship with a client who no longer requires care. Which of the following concepts should the nurse and client discuss in the termination phase of the relationship?

loss At the close of a relationship, even one that is planned, loss is an expected feeling for both the client and the nurse. It is important for both the nurse and the client to terminate the relationship without feelings of guilt or anxiety.

A nurse is preparing to provide chest physiotherapy for a client who has left lower lobe atelectasis. Which of the following actions should the nurse plan to take?

place the client in trendelenburg's position The nurse should place the client in right side lying position in Trendelenburg's position to promote drainage from the client's left lower lobe.

A nurse is preparing to administer a cleansing enema to a client. Which of the following actions should the nurse plan to take?

position to the left side