Fundamentals Final

What are the functions of the urinary structures for elimination

-urine output is related to the amount of fluid intake -waste products are diluted with water & excreted as urine

A nurse should notify the physician if

24-hour urine output is 700 mL.

The nurse enters a client's room and finds that the wastebasket is on fire. The nurse quickly assists the client out the room. Which is the next nursing action ?

Activate the Alarm

The nurse is reviewing the prescriptions of a client admitted to the hospital with a diagnosis of acute pancreatitis. Which interventions should the nurse expect to be prescribed

Administer antacids , as prescribed , encourage coughing and deep breathing , and administer anticholinergics, as prescribed

When the nurse performs a procedure using sterile technique in the patient's unit it means that

All organism have been killed or removed from the materials that come in contact with the patient

The nurse employed in a long term care facility is planning the clinical assignments for the day. The nurse knows not to assign which staff members ti the client with a diagnosis of herpes zoster ?

An unlicensed assistive personnel who has never had chickenpox

A lPN attends a session about bioterrorism including anthrax. Which statement by and attendee demonstrates the need for further teaching about anthrax ?

Anthrax bacteria produces a neurotoxin leading to a serious possibly fatal paralysis

When reinforcing dietary instructions to a client with irritable bowel syndrome whose primary symptom is alternating constipation and diarrhea, the nurse should tell the client that which foods are best to include in the diet for this disorder

Apples and whole grain bread

A low sodium diet has been prescribed for a client with hypertension. Which food selected from the menu by the client indicates an understanding of this diet ?

Baked turkey

When auscultating abnormal valvular heart sounds a nurse should hold

Bell of the stethoscope lightly to the skin

The nurse instructs a patient that in order to reduce diseases that are transmitted via droplet the nose and mouth should be covered by

Bent elbow

The nurse is preparing an intravenous solution and tubing for a client who requires IV fluids. While preparing to prime the tubing , the tubing drops and hits the top of the medication cart. The nurse plan to take which action.

Change the IV tubing

A client with heart disease is instructed regarding a low fat diet. The nurse determines that the client understands the diet of the client states to avoid which food item

Cheese

A client with a burn injury is transferred to the nursing unit, and a regular diet has been prescribed. The nurse encourages the client to eat which dietary items to promote wound healing ?

Chicken breast, broccoli, strawberries , and milk

A client has a prescription to receive 1000 ml of 5% dextrose in 0.45% sodium chloride. After gathering the appropriate equipment, the nurse takes which action first before spiking the IV bag with the tubing

Closes the roller clamp on the IV tubing

Which of the following medical conditions may require an ostomy

Colon cancer Ulcerative colitis Congenital bowel malformation

What information should be included in the nursing care plan of a patient with constipation

Consume 1 to 3 tablespoons of bran mixed with applesauce

The nurse takes into consideration that in the stage of resistance in Selye's GAS the patient

Continues to battle equilibrium

The nurse is collecting data from a client who has had benign prostatic hyperplasia in the past. To determine whether the client is currently experiencing exacerbation of BPH , the nurse should ask the client about the presence of which early symptom?

Decreased force in the stream of urine

A patient states I am not obese my entire family is large. The nurse assesses that the patient is using the defense mechanism of

Denial

A nurse smells a sweetish odor on a patient's breath. This is indication of

Diabetic acidosis

The nurse is reviewing the record of a client with Crohn's disease. Which still characteristic should the nurse expect to see documented in the record

Diarrhea

Catheterization is an appropriate intervention in which situation ?

Dilation of urethral stricture

The nurse is assigned to care for a client with a peripheral intravenous IV fusion. The nurse is providing hygiene care to the client and should avoid which while changing the client's hospital gown?

Disconnecting the IV tubing from the catheter in the vein

Fecal has contaminated the patient's bed sheet. The nurse should

Don sterile gloves and gown remove the soiled sheer replace it with a clean one and then dispose of the sheet in a plastic bag to prevent skin or clothing contact

A hospitalized client is a lacto vegetarian. Which food item should the nurse remove from the meal tray?

Eggs

Which Bacterium is most often responsible for cystitis

Escherichia coli

The nurse is making a worksheet and listing the takes that needs to be performed for assigned adult client's during the shift. The nurse writes on the plan to check the intravenous IV of an assigned client who is receiving fluid replacement therapy how frequently ?

Every hour

A LPN nurse is preparing to assist a RN nurse with removing a nasogastric tube from the client. Which interventions should be included in the procedure?

Explain the procedure , ask the client to take a deep breath and hold, pull the tube out in one continuous steady motion, and remove the device or tape securing the tube from the nose

A clear liquid diet has been prescribed for a client with gastroenteritis. Which item is appropriate to offer to the client ?

Fat-free beef broth

An elderly male patient has a poor diet and chronic constipation. The best recommended from the nurse would be

Fiber supplement daily

The point of maximal impulse of the heart is located at or close to the

Fifth intercostal space at the mid clavicular line

It has been determined that a client with hepatitis has contracted the infection from contaminated food. Which type of hepatitis is this client most likely experiencing?

Hepatitis A

The nurse is assisting with the insertion of a nasogastric tube into a client. The nurse should place the client In which position

High- Fowler's position

The nurse is instructing a client with diabetes mellitus about peritoneal dialysis. The nurse tells the client that it is important to maintain the prescribed dwell time for the dialysis because of the risk of which complication

Hyperglycemia

A LPN nurse is precepting a student assigned to care for a client with chronic pain. Which statement if made by the student indicated the need for further teaching regarding pain

I will be sure to cue in to any indicators that the client maybe exaggerating their pain

The nurse reinforces instructions to the parent of a child with meningococcal meningitis. Which statement by the parent indicates a need for further teaching ?

I will need to get my other children. The pneumococcal vaccine but the baby yet he is only 3 months

The nurse is preparing to administer an acetaminophen suppository to a child. The nurse plans which action

Insert the suppository 1-2 cm into the rectum

Which are physical examination techniques

Inspection and observation, palpation , auscultation, and percussion

The nurse is caring for a client after a Billroth 2 gastrojejunostomy procedure. During review of the postoperative prescriptions which should the nurse clarify ?

Irrigating the NG tube

The nurse explains that medical asepsis differs from surgical asepsis in that medical asepsis

Is confined to the patient's room

The nurse assess that a person is in the acceptance stage of illness when the patient

Learns to walk and maintain balance with the aid of a walker

After a client undergoes a liver biopsy, the nurse places the client in the prescribed right side lying position. The nurse understands that the purpose of this intervention is to accomplish which ?

Limit bleeding from the biopsy site

The nurse is reinforcing discharge instructions to a client after gastrectomy. Which measure should the nurse include during the client teaching to help prevent dumping syndrome ?

Limit the fluids taken with meals

A client with a hiatal hernia chronically experiences heartburn after meals. Which should the nurse teach the client to avoid?

Lying recumbent after meals

A client with renal failure has a dialysis shunt in the left arm the nurse should avoid

Measuring BP in the left arm

The nurse reports that her patient's stools are black and tarry. The nurse should document the stool as:

Melena

The nurse reinforces instructions to a client to increase the amount of riboflavin in the diet. The nurse should tell the client to select which food item that is high in riboflavin

Milk

A nurse assessing an elderly patient for dehydration. What is the best indicator on physical examination for hydration status?

Mucous membranes

The nurse takes into consideration that the patient with an admitting diagnosis of type 2 diabetes mellitus and influenza is described as having

One chronic and one acute illness

Which is the function of the respiratory system

Oxygen diffuses across the alveolar membrane into the blood.

The nurse applies wrist restraints prescribed to prevent a client from pulling out a master gastric tube. How should the nurse determine that the restraints are not too constrictive

Place two fingers under the restraint to determine snugness

The nurse has inserted a nasogastric tube in a client and is checking for the correct placement of an NG tube. Which is the most reliable data to ensure that the end of the tube is in the stomach.

Placement is verified on x Ray

A primary health care provider writes a prescription to apply a heating pad to a client's back. The nurse implements the prescription and avoid which action?

Placing the heating pad under the client

A female patient has had a knee replacement and is experiencing difficulty voiding. What should the nurse recommend ?

Pour warm water over the perineum while patient attempts to void.

What is the function of the small intestine

Processes chyme into a liquid state

Pneumatic/Sequential Compression Devices are used for

Promoting venous return to the heart

The nurse is monitoring for stoma prolapse in a client with colostomy. Which aroma observation should indicate that a prolapse has occurred ?

Protruding and swollen

A orient with primary tuberculosis is on airborne precaution and he spends much of the day sleeping and is confused and awake at night. An appropriate nursing intervention for this patient is to

Provide diversionary activities or visitors during the day to decrease his sense of isolation and sensory deprivation

A patient has increased intracranial pressure. When evaluating the patient's pupils a nurse documents which abnormal finding

Pupils react slowly to light

What is the function of the diaphragm

Relaxation of the diaphragm causes air to move out of the lungs.

The nurse is changing the neck ties on a tracheostomy tube. Which method is appropriate for the nurse to take

Remove the old ties, clean the site , and then apply the new ties while a second health care team member hold the tracheostomy tube

The nurse explains to the patient who has pneumococcal pneumonia that the lungs serve as the

Reservoir

Which test evaluates air versus bone conduction?

Rinne test

The nurse is providing dietary instructions to a client with gout. The nurse should tell the client to avoid which food item?

Scallops

The nurse believes that teaching a patient how to give insulin and Monitor blood glucose levels will improve the level of the patient's

Self esteem by promoting independence and learning

The nurse is monitoring a client for the early signs and symptoms of dumping syndrome. Which indicates this occurrence

Sweating and pallor

A LPN nurse is explaining the appropriate methods for measuring an accurate temperature to an unlicensed assistive personnel. Which method if noted by the UAP as being an appropriate method indicates the need for further teaching ?

Taking an oral temperature for a client with a cough and nasal congestion

A nurse is collecting a voided specimen for urinalysis. The nurse should

Tell the patient that only about 1.5 inches of urine is needed.

A child diagnosed with bacterial conjunctivitis and antibiotic eye drops are prescribed for the child. The parent asks the nurse when the child can return to school. The nurse should make which response to the parent

The child should be kept home until antibiotic eye drops have been administered for 24 hours

The nurse is assisting a client to ambulated when the client states he is feeling faint and cannot stand. Which action should the nurse take to assist the client now

The nurse should extend one leg to use to slide the client's body down to the floor

A client is receiving total parenteral nutrition has been NPO. The primary health care provider prescribed small amounts of clear liquids today. The nurse's priority is to collect data regarding which criterion before giving the client anything by mouth

The presence of the swallow reflex

The nurse obtains a prescription to restrain a client using a belt safety restraint and instructs the unlicensed assistive personnel to apply the restraint. Which observation if made but the nurse indicates unsafe application of the restraint ?

The restraint straps are safely secured to the side rails

The nurse instructing a patient in the home use of disinfectant would include the information that the disinfectant can be used to

Thoroughly clean and rinse all soap off the equipment before disinfecting it

A nurse is teaching a post surgical cardiac patient about interventions to prevent respiratory problems. The nurse should include

Use of an incentive spirometer can prevent or relieve atelectasis.

The most effective part of infection control to reduce the incidence of health care associated infections is to

Use proper hand hygiene before and after caring for any patient before donning gloves and after their removal

The client asks the nurse about various herbal therapies available for the treatment of insomnia. The nurse should encourage the client to discuss the use of which product with the primary health care provider ?

Valerian

A nurse auscultation soft rustling sounds in the periphery of a patient's lung field. The nurse describes the sound as

Vesicular

The nurse is caring for a client with a diagnosis of chronic gastritis. The nurse anticipates that the client is at risk for which vitamin deficiency?

Vitamin B12

The nurse is caring for a client who takes ibuprofen for pain. The nurse is gathering information on the client's medication history and determines it is necessary to consult with the RN nurse if the client is also taking which medication ?

Warfarin , Glimepiride , and Amlodipine

The nurse is assisting with planning care for a client with an internal radiation implant. Which should be included in the plan of care ?

Wearing gloves when emptying the client's bedpan, Keeping all linens in the room until the implant is removed , wearing a film badge when in the client's room, and wearing a lead apron when providing direct care

Homeostasis can be described as

a tendency of biological systems toward stability of the internal environment by continuously adjusting to survive.

A nurse notes that a patient has not had a stool for 2 days. The initial action of the nurse should be to:

ask about the patient's normal bowel pattern.

Which organs are most susceptible to slight changes in oxygenation

brain, retina, and heart

Interventions for a patient with diarrhea include

clear liquid diet

A nurse is educating a group of elderly patients in an assisted living facility about urinary incontinence. Information offered during the encounter may include?

condom catheters may be used by males.

An elderly female has had an acute stroke and is unable to ventilate on her own. Which airway is recommended

endotracheal

What initiates peristalsis

gastrocolic reflex

A client is having problems with blood clotting. Which food item should the nurse encourage the client to eat?

green leafy vegetables

A patient with chronic lung disease requires continuous oxygen per nasal cannula at home and reports significant dryness of the nose and mouth. Which is most appropriate

humidifier

The most common cause of respiratory insufficiency is

obstruction

When intermittently catheterizing an elderly patient, the nurse may

position the patient on their side

A nurse who is preparing to irrigate a wound and apply a new dressing to a client who has staphylococcus aureus should use which protective interventions ?

put on a mask , don gowns and gloves , and wear pair of protective goggles

Which age related change in the urinary system should a nurse expect

reduced rate of renal filtration

A nurse clarifies that methods of tertiary prevention are designed for

rehabilitation

fecal incontinence may be caused by what illness

stroke

The situation in which protective eyewear is required is

suctioning a tracheotomy.

What is the most common cause of airway obstruction in the unconscious person

tongue

A nurse is nasopharyngeal suctioning an adult patient to remove thick secretions. The nurse will:

use a 14-Fr catheter

The nurse should institute which interventions for a client diagnosed with clostridium difficile ?

wear gloves and gown while in the room caring for the client , use soap and water , not alcohol based hand rub for hand hygiene