Fundamentals Final Exam
A client reports to the nurse that after delivering a baby, she loses small amounts of urine each time she sneezes or laughs hard. Which type of incontinence does the nurse anticipate?
Stress
A nurse who usually works on the surgical unit is asked to float to the oncology unit because of staffing needs. Which statement by the nurse indicates the possibility of the nurse experiencing culture shock?
"I am very stressed now because I do not understand how things work on this unit."
The nurse is teaching a client about healing of a minor surgical wound by first intention. What teaching will the nurse include?
"Very little scar tissue will form"
A nurse caring for clients of different cultures in a hospital setting attempts to make eye contact with clients when performing the initial assessment. What assumption might the nurse make based on common cultural practices?
A Muslim-Arab woman refuses to make eye contact with her male nurse. Assumption: She is being modest.
Which are examples of subjective data? Select all that apply.
A client describes pain as an 8 on the pain assessment scale. A client feels nauseated after eating breakfast. A client reports being cold and requests an extra blanket.
"Acute Pain related to instillation of peritoneal dialysate as evidenced by client wincing and grimacing during procedure, client description of experience as 'stabbing'" is an example of which type of nursing diagnosis?
Actual nursing diagnosis
Which type of health problem requires both physician- and nurse-prescribed actions to address?
Collaborative health problem
The nursing diagnosis taxonomy provides nursing with:
Common language
A client asks, "Why do some foods, like corn, come out undigested in my feces?" Which is the nurse's best response?
Corn is high in cellulose, which is an insoluble fiber that the body cannot digest.
The nurse is collecting data on a client with reflex incontinence. Which information would the nurse ask the client during the physical assessment?
Do you have the sensation to urinate?
The nurse prepares to collect the client's stool for ova and parasites. Which actions should the nurse provide? Select all that apply.
Instruct client to call immediately after having the bowel movement. Teach client to not place toilet paper with stool. Transport specimen to the lab immediately. Use a biohazard bag for the specimen.
A client is admitted to the unit with a diagnosis of intractable vomiting for 3 days. What acid-base imbalance related to the loss of stomach acid does the nurse observe on the arterial blood gas (ABG)?
Metabolic Alkalosis
During a visit to the pediatrician's office, a parent inquires about adding solid foods to the diet of a 6-month-old infant. What does the nurse inform the parent?
New foods should be introduced one at a time for a period of 2 to 3 days.
The nurse is assessing a client for changes in health condition. After listening to the client's lungs for adventitious breath sounds, the nurse also checks the client's latest white blood cell count. The nurse is gathering which type of data when looking up the lab value?
Objective
A nurse is caring for a client who has a body mass index (BMI) of 26.5. Which category should the nurse understand this client would be placed in?
Overweight
The nurse is preparing to administer a client's ordered tube feeding and the client aspirates gastric contents. Testing of the pH yields a result of 5.3. What is the nurse's most appropriate action?
Proceed with the feeding as normal
A client with the history of systemic lupus erythematosus underwent a surgical repair of a right inguinal hernia. The client now presents to the emergency department with the report that the incision appears to have opened. Which action should the nurse prioritize after performing the focused assessment?
Question the use of predinisone
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
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.
Collection of a wound culture has been ordered for a client whose traumatic hand wound is showing signs of infection. When collecting this laboratory specimen, which action should the nurse take?
Rotate the swab several times over the wound surface to obtain an adequate specimen.
A nurse is evaluating a client who was admitted with partial-thickness or second-degree burns. Which describes this type of burn?
Usually moist with blisters, which may be pink, red, pale ivory, or light yellow-brown
The nurse is teaching a family, who has recently learned a family member has a lactase deficiency, how to make healthier dietary choices to ensure the family member obtains enough calcium in their diet. The nurse determines the teaching was successful when they choose which menu as the best choice?
baked salmon patty, steamed spinach, sweet potato, salad with romaine lettuce, hard-boiled egg slices, carrots, celery, cucumber, and vinegar vinaigrette dressing, apple slices, ice tea
A nurse is implementing secondary-level interventions for a group of hospitalized clients. With which activity(ies) would the nurse be involved? Select all that apply.
Administering medications Providing wound care
Which is a common anion?
Chloride
The parent of a 5-year-old child tells the nurse that on two occasions her son has lost control of urination when he had to wait to go to the bathroom at school. What is the appropriate nursing response?
"Let's review the types of fluids that your child drinks in the morning."
The nursing instructor hears students discussing fluid and electrolyte balance. Which statement would warrant further instruction?
"The kidneys store and release antidiuretic hormone to increase water retention."
The registered nurse (RN) observes the licensed practical nurse (LPN) preforming this action when applying a topical gel to a client's surgical wound during a dressing change. What instructions should the RN provide the LPN regarding this action?
"To best avoid further traumatizing the wound bed, apply the gel with a sterile cotton tip applicator."
After assessing a client, a nurse identifies the nursing diagnosis, "Ineffective Airway Clearance related to thick tracheobronchial secretions." The nurse would classify this nursing diagnosis as which type?
Actual
A client with protracted nausea and vomiting has been receiving intravenous solution at 125 ml/h for the past several hours. The administration of this solution has resulted in an increase in blood pressure because the water in the solution has passed through the semipermeable membrane of blood cells, causing them to swell. What type of solution has the client been receiving?
A hypotonic solution
How is control over the extracellular concentration of potassium within the human body is exerted?
Aldosterone
A nurse prepares to insert a nasointestinal tube to provide nutrition to a client. Which guideline is recommended for this procedure?
Begin by measuring from the tip of the client's nose to the earlobe to the xiphoid process.
Why are health promotion and illness prevention a key responsibility of nurses?
Chronic illnesses are the leading health problem in the world.
A nurse is cleaning the wound of a client who has been injured by a gunshot. Which guideline is recommended for this procedure?
Clean the wound from the top to the bottom and from the center to outside.
The nurse is gathering subjective data from a client during an interview after a suicide attempt. Which assessment data gathered by the nurse would be documented as subjective data? Select all that apply.
Client states, "I feel so sad all of the time." Client states, "I am in pain."
What should the nurse assess before application of sitz bath therapy? Select all that apply.
Client's ability to ambulate to the bathroom Client's ability to sit for 15 to 20 minutes Client's perineal/rectal area Client's need to void
A postoperative client says during a transfer, "I feel like something just popped." The nurse immediately assesses for:
Dehiscence
A nurse informs the client that the client has no choice and must take a bath in the morning. What type of leadership does this exemplify?
Directive Leadership
After a client has a myocardial infarction, the nurse formulates a possible nursing diagnosis of "Powerlessness." To determine the accuracy of the diagnosis, what would be the nurse's most appropriate action?
Discuss the client's health condition with the client.
Which are factors that impact how a client defines health? Select all that apply.
Family Culture Community Society
The nurse provides teaching to a client experiencing constipation. Which food choice on the client's breakfast tray indicates effective teaching?
Grapefruit
Which definition of health is the best?
Health is a state of complete well-being
Which are models used in nursing to assist in clustering data? Select all that apply.
Human Needs Functional Health Patterns Human Response Body Systems
What type of dressing is occlusive or semi-occlusive, limits exchange of oxygen between wound and environment, provides minimal to moderate absorption of drainage, maintains a moist wound environment, and may be left in place for three to seven days, thus resulting in less interference with healing?
Hydrocolloid
A cleansing enema has been ordered for the client to draw water into the bowel. Which type of solution does the nurse gather?
Hypertonic saline
The nurse is reviewing a client's most recent laboratory results, which reveal increases in hematocrit, creatinine, and blood urea nitrogen (BUN). After collaborating with the interdisciplinary team, what intervention is most appropriate?
Increase the client's fluid intake
Which disorders might a nurse screen for in a black client, based on race? Select all that apply.
Keloid formations Lactase deficiency Sickle cell anemia
The nurse recognizes that a new mother is having difficulty breastfeeding. The nurse demonstrates various positions in which to hold the baby while feeding. The nurse also educates the mother on ways to ensure proper latching. The new mother attempts to breastfeed the baby again using the new techniques and is successful. Which statement in this scenario illustrates Lewin's stage of refreezing?
The new mother attempts to breastfeed the baby again using the new techniques and is successful.
Following a myocardial infarction (heart attack), a client begins to recognize the need to increase exercise, eat a low-fat diet, and implement relaxation techniques. According to Lewin, this client is in which stage of the change process?
Unfreezing
The nurse is reviewing the chart of an older adult client who exhibits signs of confusion. Which laboratory value would indicate to the nurse that intervention is needed?
Urine culture sensitivity - 100,000/mL
Which vitamin is found only in animal foods?
Vitamin B12
A client who is NPO prior to surgery reports feeling thirsty. What is the physiologic process that drives the thirst factor?
decreased blood volume and intracellular dehydration
The nurse is teaching a community group about reading food labels. When teaching about avoidance of refined sugar, the nurse will teach people to avoid foods containing which ingredients.
molasses corn syrup corn sweetener brown sugar
The nursing instructor is teaching students about assessment and the importance of having baseline data when caring for clients. The instructor should inform the students that the best place to get baseline data is:
the initial comprehensive client assessment.
