Fundamentals Part 5
A nurse is responding to a parent's question about his infants expected physical development during the first year of life which of the following pieces of information should the nurse include?
A 10 month old infant can pull up to a standing position
A nurse is preparing to insert an indwelling urinary catheter which of the following instructions should the nurse give the client to ease the passage of the catheter through the urinary meatus?
"Bear down " the nurse should ask the client to bear down gently as if to avoid this can enable the nurse to better visualize the urinary meatus and promote relaxation of the external urinary sphincter additionally this will ease the passage of the catheter through the urinary meatus
A nurse is caring for a client who has injuries resulting from a motor vehicle crash which of the following client statements should the nurse address first ?
"I can't sleep well because whenever I move in my sleep the pain wakes me up "
A nurse is conducting a health promotion class for a group of college students which of the following statements by student should the nurse identify as a potential problem with achieving erikson's developmental tasks for this age group ?
"I go home on the weekends to be with my family because I do not have any good friends here on campus" in ericksons this stage of physiological development is intimacy versus isolation the statement indicates that the students having difficulty establishing relationships outside of the immediate family
A nurse is admitting a client who has tuberculosis in addition to standard precautions which of the following transmission based precautions should the nurse add to the client's plan of care ?
Airborne because tuberculosis requires airborne precautions which are protocols that prevent the spread of infection via very small droplets like measles and varicella
A nurse on a medical surgical unit is admitting a client which of the following pieces of information should the nurse document in the client's record first ?
An assessment because before the client can formulate any plan of action implement a nursing intervention or even notify a provider of a change of client status the nurse must collect adequate data
A nurse discovers that a client receiving the wrong medication which of the following actions should the nurse take first ?
Assess the client and make sure there are no adverse effects
A nurse in a providers office is teaching a client about foods that are high in fiber which of the following food choices made by the client indicate an understanding of the teaching ?
Black beans and whole grain grain bread is high in fiber
A nurse is caring for a client who is receiving total parenteral nutrition which of the following actions should the nurse take ?
Check the clients capillary blood glucose every four hours because according to facility policy due to the client's risk of hypo hyperglycemia while receiving TPN the dextrose concentration in TPN increases the risk of this complication
A charge nurse is teaching adult cardio pulmonary resuscitation CPR to a group of newly licensed nurses which of the following actions should the charge nurse teach as the first response to CPR?
Confirm unresponsiveness
A nurse is teaching a client who is post operative about the importance of turning coughing and breathing deeply which of the following statements should the nurse identify as an indication that the client understands the instructions ?
If I do this often I won't get pneumonia because turning coughing and breathing deeply will help prevent respiratory complications such as pneumonia by promoting lung expansion and secretion removal
A nurse is caring for a client who is unstable and has vital signs measured every 15 minutes by an electronic blood pressure machine the nurse notices the machine begins to measure the blood pressure at varied intervals and the readings are inconsistent which of the following actions should the nurse take ?
Disconnect the machine and measure the blood pressure manually every 15 minutes because if the nurse questions reliability of monitoring equipment a manual process should be used also malfunctioning equipment can pose a safety risk for the clients so it must be tagged and removed
A nurse is assessing a client which of the following findings should the nurse identify as an indication of protein calorie malnourishment ?
Dry brittle hair edema and poor wound healing . dry brittle hair that falls out easily suggests inadequate protein intake and malnourishment while adima can occur when albumin levels are lower than the expected reference range and indicates protein calorie malnourishment adequate wound healing depends on the ingestion of sufficient protein calories water vitamins especially CNA iron and zinc
A nurse is caring for a client who is receiving Ivy therapy via the peripheral catheter the nurse should identify that which of the following findings is an indication of infiltration ?
Edema at the infusion site because edema due to fluid entering subcutaneous tissue is an indication of infiltration
A nurse is performing a comprehensive physical assessment of a client the nurse should use inspection to assess which of the following ?
Gait Because inspection is the technique of looking or observing gait inspection involves watching the clients walking movements and observing any unusual findings
A nurse is changing the dressings for a client recovering from an appendectomy following up ruptured appendix the client's surgical wound is healing by secondary intention which of the following observations should the nurse report to the provider ?
Halo of erythema on the surrounding skin because the nurse should report to the provider when the client has a ring of redness on the surrounding skin which might indicate underlying infection this and any other manifestation of infection like purlent drainage swelling warmth or strong odor should be reported to the provider
A nurse is caring for a client who has a tracheostomy and requires suctioning which of the following actions should the nurse take ?
Hyper oxygenate the client before sectioning because the nurse should use a manual resuscitation bag to hyper oxygenate the client for several minutes prior to suctioning
A client who has glaucoma of the right eye self administers timolol eyedrops by looking at the ceiling and stealing a drop into the center of the conjunctive ilsac and applying gentle pressure to the lower lid with the facial tissue after observing this the process which of the following actions should the nurse take ?
Instruct the client to apply pressure to the inside corner of the eye after installation because it will prevent the medication from flowing into the nasal passages where systemic absorption could result
A nurse in an acute care facility is planning care for a client who is alert but temporarily immobile due to a total hip arthroplasty which of the following interventions should the nurse planted make to prevent a complication of immobility ?
Instructing the client to perform foot and leg exercises every one to two hours while awake to help prevent thrombophlebitis
A nurse is teaching a group of unit nurses about the experiences of a client who has been having surgery and which phases of care is the client transferred to the surgical suite table before being transferred to the PACU ?
Intra operative care begins when the client is transferred to the surgical suite table and ends when the client is admitted to the PACU
A nurse is planning care for a client who has anorexia and nausea due to cancer treatment which of the following interventions should the nurse include ?
Limit drinking liquids with food because drinking beverages with food leads to early satiety and bloating which results in the client consuming fewer calories
A nurse is planning care for a client who reports abdominal pain an assessment by the nurse reveals the client has a temperature of 102.6 a heart rate of 105 per minute and a soft nontender AB dominant and men's is overdue by two days which of the following findings should the nurse make as its priority ?
Temperature Not heart rate because the client's heart rate is elevated possibly due to the fever and some kind of pain so it's not the priority to deal with the heart rate more so about the temperature because it is a physiological need
A nurse is caring for a client who is unconscious which of the following actions should the nurse take when providing oral care for the client ?
Testing for the presence of the client's gag reflex because the nurse is responsible for checking for the presence of the gag reflex prior to performing oral care this is done to determine the risk of aspiration and is especially important for clients who are unconscious because many clients who have a decreased level of consciousness often do not have a gag reflex
A nurse is teaching a client about the use of straight legged cane which of the following client actions indicates an understanding of the teaching ?
The client holding the cane on the unaffected side the nurse should instruct the client to hold the cane on the unaffected side to provide a wide base of support and stability
A nurse is preparing to administer an afternoon dose of ampicillin to a client the client appears upset and refuses to take the medication before throwing the pills on the floor which of the following entry should the nurse enter into the clients medical record ?
The client threw the medication on the floor
A nurse is preparing to insert an indwelling urinary catheter for a male client which of the following locations should the nurse secure the urinary catheter tubing ?
The lower abdomen because after inserting an indwelling urinary catheter the nurse should secure the catheter tubing to the client's upper thigh or lower abdomen and by using adhesive tape or catheter securement device this location will decrease tension and trauma to the urethra
A nurse is performing an abdominal assessment of a client which of the following positions should the nurse tell the client to assume for this examination ?
The supine because the nurse should tell the client to assume the supine position to promote relaxation of the abdominal muscles having the client bend the knees enhances relaxation of the stomach muscles
A nurse is performing eye irrigation for a client who was exposed to smoke and ash which of the following actions should the nurse take ?
exerting pressure on the Bony prominences when folding the eyelids open as The nurse should hold the upper eyelid against the eyebrow and the lower eyelid against the cheekbone when irrigating the eye
A nurse in the emergency department is assessing a client who has deep rapid respirations arterial blood gas analysis include the following values pH 7.25 PaCO2 of 40 and HCO3 of 18 which of the following acid base imbalances should the nurse identify and report to the provider?
metabolic acidosis because A pH of 7.25 indicates acidosis. if the causes respiratory pH and pH CO2 values will deviate in opposite directions since the PaCO2 is within the expected reference range of 38 to 42, despite the low pH, the cause must be metabolic therefore the nurse should report to the provider that the client has metabolic acidosis
A nurse is caring for a middle aged adult client today she identified which of the following statements as an indication that the client has completed erikson's developmental tasks for her age group ?
"I think I've done a good job with my children since they are all independent now " middle adults help shape future generations through community involvement parenting mentoring and teaching the statement about helping her children achieve independence indicates that the client has accomplished this developmental task
A nurse is instructing client about collecting a 24 hour urine specimen for creatinine clearance which of the following statements should the nurse identify as an indication that the client understands the procedure ?
"I'll make sure to keep the collection bottle in the container of ice they gave me" because the urine collection must remain chilled to prevent any changes in urine composition during the collection
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 a bed " this response addresses the feelings of the partner by reflecting her feelings which facilitates therapeutic communication because it is non judgmental and encourages the partner to express her feelings
A nurse is talking with a parent of a preschool age child who tells the nurse my child has suddenly become disinterested in certain foods which of the following statements should the nurse make ?
"Keep a diary of the foods your child eats each day " this can help the parent realize that the child may be eating better than expected because evidence suggests the Childs can actually self regulate their calorie intake when they eat less at a meal they can compensate by eating more at another meal by or by having a quick snack
A nurse is providing teaching's about crotches to a client who has a fractured right foot which of the following instructions should the nurse include ?
"Keep the rubber crutch tips securely in place" because the client should never use crotches without the rubber crutch tips the clients should inspect the tips regularly replace them when they show signs of wear and remove and dry them thoroughly with paper towels if they become wet
A nurse in a providers office is assessing a client who has heart failure the client has gained weight since her last visit and her ankles are Eddie metos which of the following findings is another clinical manifestation of fluid volume access?
A bounding pulse is an expected finding of fluid volume access
A nurse is teaching a client who has urinary incontinence about bladder retraining which of the following instructions should the nurse include ?
"Try to block the urge to urinate until the next scheduled time " tried slow deep breathing to help reduce the urge and try five or six strong and quick pelvic muscle exercises
a nurse is caring for a client who starts to experience a seizure while sitting in a chair 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
A nurse is caring for a client who is receiving mechanical ventilation via a tracheostomy tube and has a gastrostomy tube for enteral feedings which pieces of information are critical to communicate to the next nurse who will be caring for this client ?
New prescriptions arterial blood gas results and tracheal secretion characteristics
A nurse is caring for an older adult client who has dysphasia following a cerebral vascular accident which of the following actions should the nurse take when assisting the client at meal time ?
Offer the client tart or sour foods first because a client who has impaired pharyngeal swallowing should consume tart and sour foods at the beginning of their meal to stimulate saliva production which aids chewing and swallowing
A nurse is assessing the heart sounds of a client who has developed chest pain that worsens with inspiration the nurse auscultrates a high pitch scratchy sound during both sistol and distal with the diaphragm of the stethoscope position at the left sternal border which of the following heart sounds should the nurse document?
Pericardial friction rub because a pericardial friction rub has a high pitch scratchy grading or squeaking leathery sound that is heard best with the diaphragm of the stethoscope at the left sternal border . a pericardial friction rub is a manifestation of pericardial inflammation and can be heard with infection pericarditis with myocardial infarctions following cardiac surgery or trauma and with some autoimmune problems like rheumatic fever a client who develops pericarditis typically has chest pain that becomes worse with inspiration or coughing and may be relieved by sitting up and leaning forward
A nurse is preparing to perform mouth care for an unresponsive client which of the following actions should the nurse plan to take?
Raise the clients level of the bed to allow for proper use of body mechanics and reduce the risk of self injury
A nurse is preparing to administer a bolus feeding to a client through an Ng tube and observes that the client exit mark on the tube has been removed since the last feeding which of the following actions should the nurse plan to make ?
Request an X ray of the clients AB dominant just to verify the placement of the N G2 both after the initial insertion of the tube and if displacement of the tube is suspected
A nurse is reviewing the laboratory data of a client who has a fever and watery diarrhea which of the following results should the nurse report to the provider ? calcium 9.5 sodium 150 potassium four magnesium 1.5
Sodium 150 is greater than the expected reference range of 135 to 1:45 this is a risk for the client because they may be dehydrated due to the diarrhea hypernatremia is a manifestation of dehydration and the nurse should report this to the provider
A nurse is caring for a client who has xerostomia with the lack of saliva which of the following nutrients will be affected by the lack of saliva amylase?
Starch
A nurse is measuring the clients vital signs the client's heart rate is 105 beats per minute the nurse should document the finding is which of the following alterations ?
Tachy cardia because it is a rate that's over 100 beats per minute and adults whereas Brady cardia as a heart rate under 60 beats per minute in adults