Fundamentals Practice #2

A nurse is assisting a client with range-of-motion exercises of the feet and ankles. Which of the following terms should the nurse use when documenting the client extending her leg and bending her foot and toes downward toward the floor?

Plantar flexion

A nurse is planning to monitor a client for dehydration following several episodes of vomiting and an increase in the client's temperature. Which of the following findings should the nurse identify as an indication that the client is dehydrated?

Urine specific gravity 1.034

A nurse is caring for a client who has right-sided paralysis from a cerebral vascular accident (CVA). Which of the following interventions should the nurse implement?

Use a footboard to maintain dorsiflexion of the feet.

A nurse is obtaining a urine specimen for culture and sensitivity via a straight catheterization. Which of the following actions should the nurse take?

Use a sterile specimen container.

A nurse is caring for a client who is to maintain a fluid restriction of 1,200 mL/24 hr. During the first 4 hr of the shift the client had a total fluid intake of 300 mL. How many mL of fluids can the client have over the next 16 hr?

900 ml

A nurse is collecting data about the fluid status of four clients. Which of the following clients should the nurse identify as being at risk for fluid volume deficit?

A client who has gastroenteritis and is receiving oral fluids

A nurse is reinforcing preoperative teaching about pain management using a patient-controlled analgesia (PCA) system with a client. Which of the following three statements should the nurse include?

"There is minimal risk of an overdose of pain medication while using the PCA pump" is correct. "Using the PCA regularly will provide a constant level of pain relief" is correct. "Push the button on the PCA prior to your pain level becoming severe so you can remain comfortable" is correct.

A nurse is planning care for a client who is immobile and requires continuous mitten restraints. Which of the following interventions should the nurse contribute to client's care plan?

-Document restraint checks every 2 hr. -Educate the client's family about restraint use. -Implement passive range-of-motion exercises.

A nurse in an extended-care facility is reinforcing teaching for with a group of newly licensed nurses about the expected physiologic changes of aging. Which of the following information should the nurse include?

-More difficulty seeing due to a greater sensitivity to glare -Decreased cough reflex -Decreased bladder capacity -Dehydration of intervertebral discs

A nurse is preparing to administer hydrocortisone 100 mg IM daily to a client. Available is hydrocortisone 250 mg/2 mL. How many mL should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

0.8

A nurse is caring for a client whose belongings were lost in a hurricane. The client says, "What's the use in starting over? It will probably happen again." Which of the following responses should the nurse make?

"It appears you are feeling hopeless."

A nurse is caring for a school-age child who has metastatic osteosarcoma. While the parents are away, the child is crying and asks the nurse if she is going to die. Which of the following is an appropriate response by the nurse?

"Let's talk about it. Tell me more about what you are thinking."

A nurse is caring for a client who has a percutaneous endoscopic gastrostomy (PEG) tube and is prescribed to receive 40 mL of fluid replacement every 4 hr for each 100 mL of output. The client's output over the last 4 hr was 250 mL. How much water should the nurse administer to the client? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

100

A parent of a school-age child tells the nurse in the family practice clinic that she is concerned about the amount of sleep her son is getting. The nurse should explain that school-age children should get at least which of the following amounts of sleep each night?

11 hr

A nurse is calculating a client's intake and output for an 8-hr shift. The client's intake included 1,000 mL 0.9% sodium chloride IV solution, one 6-oz cup of coffee, 6 oz of water, one 180-mL bowl of soup, 3 oz of flavored gelatin, and 3 oz of ice cream. How many mL should the nurse document as the client's total intake for the shift?

1720

A nurse is caring for a client who has a prescription for digoxin 0.25 mg PO daily. The amount available is digoxin 0.125 mg/tablet. How many tablets should the nurse administer per dose?

2

A nurse is assisting with the admission of a client who is dehydrated. Which of the following BUN levels should the nurse expect the client to have?

24 mg/dL

A nurse is caring for a client who has impaired renal function. The nurse should notify the provider if the client's hourly urine output falls below what amount?

30

A nurse is calculating the total fluid intake for a client during an 8-hr period. The client had an IV bolus of 150 mL and consumed 4 oz of juice, 6 oz of hot tea, 100 mL of water, and 8 oz of clear broth. The nurse should record how many mL of intake on the client's record?

790 ml

A nurse is assisting a client with range-of-motion exercises of the shoulders. Which of the following terms should the nurse use when documenting the client raising his arm from his side to above his head?

Abduction

A nurse is caring for a client whose right leg is in Buck's traction. Which of the following should the nurse implement to promote mobility?

Active range-of-motion exercises of the left leg

A nurse is assisting a client with range-of-motion exercises of the hip. Which of the following terms should the nurse use when documenting the client moving one leg in the direction of her body's median and past it?

Adduction

A nurse is reviewing a provider's prescriptions for a group of clients. Which of the following client prescriptions should the licensed practical nurse (LPN) clarify with the provider?

Administer 1 g of vancomycin intrathecally.

A nurse is assisting with the admission of a client who has tuberculosis with a productive cough. Which type of isolation precautions should the nurse initiate for the client?

Airborne

A nurse is orienting a newly licensed nurse about obtaining telephone prescriptions. Which of the following statements by the new nurse indicates a need for further teaching?

All telephone prescriptions must be directly transcribed into the nurse's notes."

The family of a client who has died unexpectedly arrives immediately after the death. Which of the following actions should the nurse take?

Allow the family to view the body privately.

A nurse is reinforcing teaching with an adult client who has a low literacy level about the subcutaneous administration of medication. Which of the following strategies should the nurse use to promote the client's understanding?

Ask the client to demonstrate the skill.

A nurse is reviewing the medical record for a client who has pneumonia. The nurse should plan to have the client lie on his back with his head lower than his feet to mobilize secretions from which of the following lung segments?

Anterior segments of both lower lobes

A nurse is contributing to the plan of care for a client who has frequent diarrheal stools. Which of the following interventions should the nurse include in the plan?

Apply an alcohol-free barrier to the perineal area after each stool.

A nurse is caring for a client who has is requesting information about how to enhance her immune system. The nurse should identify that which of the following complementary and alternative healing modalities uses the essential oils of plants to provide psychological and physiological benefit.

Aromatherapy

A nurse is interviewing a female client who does not speak the same language as the nurse. The client's partner is translating what the nurse is saying to the client. Which of the following actions should the nurse take?

Arrange to complete the data collection with only the client and a translator present.

A nurse is caring for a client who is postoperative. When helping to manage the client's pain, which of the following principles should the nurse apply? (Select all that apply.)

Consider the client's individual expression of pain. Use a scale from 0 to 10 to monitor the severity of the client's pain.

A nurse is planning care for a group of clients. When planning the assignment for an assistive personnel (AP), which of the following activities should the nurse consider unsafe for the AP to perform?

Assisting an older adult client to take acetaminophen the AP crushed in applesauce

A nurse is preparing to administer a pre-packaged oral medication to a client and complete the final medication check. At which of the following times or places should the nurse perform this final check?

At the client's bedside before administration

A nurse is evaluating an older adult client who is receiving end-of-life care and has Cheyne-Stokes respirations. Which of the following observations should the nurse identify as confirmation of this respiratory pattern?

Breathing ranging from very deep to very shallow with periods of apnea

A nurse is observing an assistive personnel (AP) who is preparing to deliver a meal tray to a client who practices Orthodox Judaism. On the tray is a roast beef dinner with nonfat milk. Which of the following actions should the nurse take?

Call the dietary department and ask for a kosher meal tray.

A nurse is assisting with the care of a client who has developed cardiogenic shock. When evaluating circulation to the client's brain, which of the following pulse sites should the nurse use?

Carotid

A nurse is preparing a sterile field. Which of the following actions should the nurse take first?

Center the sterile pack on the work surface.

A nurse is assisting a client with range-of-motion exercises of the hip. Which of the following terms should the nurse use when documenting the client moving her leg so that she is tracing circles with her foot?

Circumduction

A nurse is about to give a client a complete bed bath. Which of the following actions should the nurse take to maintain the client's privacy?

Close the curtains around the client's bed

A nurse is reinforcing teaching to a client who has a wrist injury. In describing range-of-motion exercises, the nurse should explain that the wrist is which of the following types of joints?

Condyloid

A nurse is reinforcing dietary teaching with a client who is Asian-American and looks at the floor during the instruction. Which of the following actions should the nurse take to demonstrate cultural sensitivity?

Continue the discussion while avoiding eye contact.

A nurse is caring for an older adult client in a long-term care facility. Which of the following measures should the nurse take first when assisting with planning the client's care?

Determining the client's mobility

A nurse receives a client's laboratory results and notes a potassium level of 3.1 mEq/L. When reviewing the client's medication administration record, which of the following types of medication should the nurse identify as a contributing factor to the client's electrolyte imbalance?

Corticosteroids

A nurse is caring for a client whose hysterectomy wound has eviscerated. Which of the following actions should the nurse take?

Cover the wound with a moist sterile dressing.

A nurse on a medical-surgical unit is assisting with the admission of a client who has vision loss. Which of the following actions is the nurse's priority?

Describe the environment to the client.

A nurse is contributing to the plan of care for a client who has a disturbed body image following a motor vehicle crash that resulted in a right arm amputation. Which of the following actions should the nurse take first?

Determine the client's perception of his body image.

A nurse is caring for a client who follows Halal, Islamic dietary laws. The nurse should recognize that the client will practice which of the following dietary practices?

Does not eat birds of prey.

A nurse is caring for a client and is establishing a nurse-client helping relationship. Which of the following communication techniques should the nurse use during the orientation phase?

Elicit information from the client.

A nurse is caring for a client who is to undergo surgery the next day. The client tells the nurse, "I'm afraid of what's going to happen." Which of the following responses should the nurse make?

Encourage the client to discuss her fears further.

A nurse is caring for a client who has become increasingly anxious and confused. Which of the following actions should the nurse implement to avoid the use of physical restraints? (Select all that apply.)

Ensure effective pain management. Attend to the client's needs for toileting. Assign the client to a room near the nurse's station. Orient the client frequently to the environment.

A nurse is collecting data from an adolescent client. Which of the following behaviors should the nurse expect an adolescent who has achieved successful resolution of the developmental tasks of identify vs. role confusion to exhibit?

Establishes a close relationship with another person

A nurse is caring for a client who is competent, refuses further treatment, and asks to sign out of the hospital against medical advice (AMA). The nurse notifies the charge nurse, who tells the nurse that the provider has recommended restraining the client, if necessary, to keep her from leaving the hospital. The nurse refuses to implement the action based on the knowledge that restraining this client would be committing which of the following torts?

False imprisonment

A nurse is providing postmortem care for a client. Identify the sequence of steps the nurse should follow. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

First, the nurse must make sure the provider has pronounced the client dead. The nurse should note the time of death and interventions at that time. Verifying organ and tissue donation status is the second step due to time sensitivity. After the provider confirms the death, the nurse must validate if the client is an organ or tissue donor to ensure notification of the appropriate individuals. If the client will have an autopsy, tubes, equipment, and indwelling lines must remain in place until the coroner deems otherwise or if the facility's policy has other requirements. Next (or after the autopsy), the nurse should remove all equipment, tubes, and indwelling lines. Then, the nurse should cleanse the body and leave dentures in the client's mouth and hairpieces in place to present the most natural appearance possible before the family views the body and says goodbye to the client. After that, the nurse should attach identification tags prior to transport.

A nurse is caring for a client and is preparing to insert a large bore NG tube. Identify the order of the steps the nurse should perform. (Move the steps of NG tube placement into the box on the right, placing them in the selected order of performance. Use all the steps.)

First, the nurse should place the tube in a basin of warm water. Placing the tube in a basin of warm water will make the tube more pliable and flexible, facilitating insertion. Next, the nurse should measure how far to insert the tube. The nurse should determine how far to insert the tube by measuring the tubing from the tip of the nose, to the tip of the ear lobe, to the tip of the xiphoid, and mark the place with adhesive tape. The next step is to lubricate the tip of the tube. The nurse should lubricate the tube with a water-soluble gel or water to facilitate passing the tube through the nares. Using an oil-based lubricant can result in respiratory complications as it does not dissolve. After lubricating the tip of the tube, the nurse should insert the tube. The nurse should ask the client to extend his neck back against the pillow to facilitate the initial passage of the tube. The nurse should gently insert the tube slowly, aiming the end of the tube downward. When the nurse has advanced the tube to just above the oropharynx, the nurse should instruct the client to flex the head forward, take a sip of water, and swallow. The flexed position closes off the upper airway to the trachea and opens the esophagus. Swallowing closes the epiglottis over the trachea and helps move the tube into the esophagus. Swallowing water reduces gagging or choking. Sipping of the water also aids passage of the NG tube into the esophagus. The last step is to obtain an x-ray. The nurse should verify placement after inserting the NG tube. The nurse should ask the client to talk, inspect the posterior pharynx for coiled tubing, aspirate gastric contents and observe the color, test the pH of gastric contents (a pH of 4 or less is expected), and confirm placement with an x-ray (this is the most accurate method to verify placement).

A nurse assisting a provider with a sterile procedure prepares to pour a sterile solution onto a piece of gauze. In which order should the nurse perform the steps of pouring the solution? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

First, the nurse should remove the bottle cap in preparation for pouring the solution, being careful not to touch the inside of the cap or the neck of the bottle. Then the nurse should place the bottle cap with the inside facing up on a clean surface to keep the inside of the cap sterile. Next, the nurse should pick up the bottle with its label facing his palm. This keeps the solution from running down the side of the bottle, which may wet and fade the label. The nurse should then pour 1 to 2 mL into a receptacle and discard it later. This cleans the inside lip of the bottle in preparation for the next pouring of the solution, which will be onto the sterile surface of the gauze. He should make sure the mouth of the bottle does not touch the sterile gauze, but he should not hold it high enough to cause splashing of the solution. The nurse should also hold the bottle outside the edge of the sterile field, not over it.

A nurse is preparing to perform postmortem care for a client who has died. Complete the following sentence by using the list of options.

First: confirm the time of death was certified Secondly: Identify the client using two identifiers

A nurse is assisting a client with range-of-motion exercises of the neck. Which of the following terms should the nurse use when documenting the client touching her chin to her chest?

Flexion

A nurse is caring for a client who reports difficulty sleeping while in the hospital. Which of the following actions of the assistive personnel (AP) while the client is sleeping should prompt the nurse to intervene?

Flushes the client's toilet after emptying the urinary catheter's drainage bag

A nurse withdraws morphine 2 mg from a vial that contains 4 mg/mL to inject IM for a client. Which of the following actions should the nurse take for wasting the excess medication?

Have a second nurse witness the disposal of the excess medication.

A nurse is planning to reinforce teaching with a client who has a low health literacy level. Which of the following methods should the nurse use?

Have two information sessions

A nurse assisting with a staff in-service is discussing aspiration. Which of the following descriptions should the nurse include in the teaching as a manifestation dysphagia?

Inconsistent vocal ability after swallowing

A nurse is removing a wound dressing that is saturated with blood and purulent drainage. Which of the following methods should the nurse use when disposing of the soiled dressing?

Place the dressing in a biohazardous waste container.

A client receiving a cleansing enema reports mild cramping. After a few minutes, he asks the nurse to stop the enema and allow him to go to the bathroom. Which of the following actions should the nurse take?

Lower the height of the solution bag.

A nurse is planning to insert an indwelling urinary catheter for an adult female client. Which of the following actions should the nurse plan to take?

Lubricate the catheter 2.5 to 5 cm (1 to 2 in).

A nurse is collecting data from a client who has had paraplegia for several years. Which of the following physiologic changes due to immobility should the nurse consider when evaluating this client's overall status? (Select all that apply.)

Muscle atrophy Venous pooling Urinary stasis

A nurse is collecting data about a client's fall risk . Which of the following findings places the client at risk for a fall?

Orthostatic blood pressure Parkinson's disease Furosemide Potassium level on day 2

A nurse is caring for a client whose hand movement is limited. Which of the following actions should the nurse take to assist the client with feeding?

Provide an adaptive feeding device for the client.

A nurse is caring for an older adult client who has a hip fracture and will require rehabilitative care. The client's family asks the nurse for information about this type of care. Which of the following statements should the nurse make?

Rehabilitation began with the client's admission to the hospital."

A nurse is reinforcing teaching with a newly licensed nurse about respecting a client's personal space. The nurse should include in the teaching that which of the following activities actions require client consent? (Select all that apply.)

Removing the client's dentures Palpating for pedal edema Taking a radial pulse

When auscultating a client's lungs, the nurse identifies crackles in the left posterior base. Which of the following actions should the nurse take?

Repeat the auscultation after asking the client to breathe deeply and cough.

A newly licensed nurse has obtained a capillary glucose level from a client that produced inaccurate results and reports this to the charge nurse. Which of the following actions should the charge nurse take?

Repeat the capillary glucose levels.

A nurse is assisting a client with range-of-motion exercises of the neck. Which of the following terms should the nurse use when documenting the client turning her head laterally from one side to the other?

Rotation

A nurse is caring for a client who is receiving heat applications using an aquathermia pad. Which of the following actions should the nurse take when applying the pad?

Stop the treatment if the client's skin becomes red.

A nurse is caring for a client who has an IV pump that begins to alarm. Which of the following actions should the nurse take?

Tag the pump and notify engineering.

A nurse removes an indwelling urinary catheter that an older adult client has had in place for 2 days. The nurse should monitor the client for which of the following expected outcomes after catheter removal?

Temporary urinary retention

A nurse is caring for a client in a long-term care facility who is receiving enteral feedings via an NG tube. Which of the following actions should the nurse take prior to administering the tube feeding?

Test the pH of gastric aspirate.

A nurse is reviewing the goals of a nurse-client therapeutic relationship with a newly licensed nurse. Which of the following information should the nurse include in the teaching?

The client achieves optimal personal growth.

A nurse in a long-term care facility sees a client who is choking. Which of the following data should the nurse identify as requiring an abdominal thrust?

The client cannot speak.

A nurse is collecting data from a client at a follow-up clinic visit for acute low back pain. A goal for this client is to use proper body mechanics at all times. Which of the following findings indicates that the client is meeting this goal?

The client faces the direction of movement when sliding an object across the floor.

A nurse is collecting data from a client who has a wrist restraint in place. Which of the following findings should the nurse identify as an indication of a complication of the restraint?

The client's hand is cool and pale.

A nurse is preparing to exit the room of a client who has a draining wound that contains methicillin-resistant Staphylococcus aureus (MRSA) and requires contact precautions. Identify the sequence the nurse should follow to remove personal protective equipment (PPE) after caring for this client. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)

The nurse should remove the most contaminated item of PPE first and the least contaminated item last. The gloves are the most contaminated, so the nurse should remove them first, and then the eyewear, the gown, and finally, the mask.

A nurse is reinforcing teaching with the parents of a child who is starting to use a spacer with a metered-dose inhaler (MDI) to treat asthma. Which of the following information should the nurse include in the teaching?

The spacer increases the amount of medication delivered to the lungs.

A nurse identifies an extravasation of a vesicant solution at a client's peripheral IV catheter's insertion site. Identify the sequence in which the nurse should perform the following actions. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)

To eliminate any further injury to the client from the vesicant (a medication that injures tissues if it leaks from a vein), the nurse should first stop the infusion. The second step is to disconnect the catheter from the tubing. The third step is to attach a 3- to 5-mL syringe to the catheter. The fourth step is to aspirate any IV solution remaining in the hub and in the catheter. The final step is to remove the IV catheter, and while avoiding exerting pressure on the site, covering it with a dry dressing.

A nurse is caring for a client who receives intermittent enteral feedings through an NG tube. Before administering a feeding, the nurse should measure the gastric residual for which of the following purposes?

To identify delayed gastric emptying

A nurse is caring for an older adult client who is Chinese and is recovering from a bowel obstruction. The client is prescribed a clear-liquid diet and asks the nurse for a cup of hot ginger tea. The nurse should identify that this request is for which of the following purposes?

To promote digestion

A nurse is performing wound care for an older adult client who has a stage I pressure ulcer. Which of the following types of dressings should the nurse apply to the wound?

Transparent

A nurse in a long-term care facility is caring for a client who is unresponsive. When performing oral hygiene for the client, which of the following actions should the nurse take?

Turn the client on his side before starting oral care.

A nurse is preparing an in-service presentation about preventing health care-associated infections (HAIs). The nurse should include which of the following as a common cause of these infections?

Urinary catheterization

A nurse is collecting data from a client who has dehydration. Which of the following findings should the nurse expect?

Urine output 20 mL/hr

A nurse is caring for a group of clients. For which of the following tasks should the nurse plan to wear protective eye equipment?

Withdrawing cord blood from a neonate Suctioning secretions from a child's newly placed tracheostomy tube

A charge nurse is observing a nurse performing a Mantoux tuberculin skin test for a client. Which of the following actions should prompt the charge nurse to intervene?

Withdrawing the needle and massages the site gently

A nurse is monitoring a postoperative client who is unable to respond to questions. Which of the following nonverbal behaviors should the nurse identify as an indication that the client is experiencing pain?

​Restlessness ​Grimacing Clenching

A nurse in a dialysis center is caring for a client who has a new diagnosis of end-stage renal disease. At the first dialysis treatment, the client tells the nurse, "I decided to come today, but I am not sure if I will need to come back again this week. I am feeling much better since my discharge from the hospital and I think my kidneys are working again." The nurse should recognize the client is demonstrating which stage of Kübler-Ross's stages of grieving?

​Denial

A nurse is caring for a client who requests pain medication. Which of the following actions should the nurse perform first?

​Determine the location of the pain.

A nurse is preparing to perform wound care and remove staples from a client's surgical incision following a hip replacement. Identify the sequence the nurse should follow. (Move the steps of staple removal into the box on the right, placing them in the selected order of performance. All steps must be used.)

​First, the nurse should remove the wound dressing in a manner that keeps the client from seeing the underside, which could cause distress or nausea. Then, when cleaning a surgical incision, the nurse should first clean the least contaminated portion of skin (the incision) using sterile technique before cleaning the periwound skin. Next, the nurse should continue with sterile technique and clean the skin beside the wound. The nurse can use a vertical swipe down the sides, or clean horizontally starting beside the wound. Then the nurse should initiate staple removal by removing every other staple first to insure the wound borders remain intact. If no gaping is noted along the incision line, the nurse can remove the remainder of the staples. The provider might prescribe the nurse to apply wound-closure strips across the incision following staple removal.

A home health nurse is caring for a client who has emphysema and has difficulty with mobility. The client spends most of his day in a reclining chair. Which of the following physiological responses to prolonged immobility should the nurse expect?

​Increased calcium excretion

FLAG A nurse is caring for a client and asks the client to share personal stories. The nurse is using which of the following interventions to promote the nurse-client relationship?

​Narrative interaction

A nurse enters a client's room and sees smoke coming from the client's trash can. Which of the following actions should the nurse take first?

​Rescue the client from immediate danger.

A nurse is assisting with the admission of a client who is hyperventilating, reports lightheadedness and paresthesias, and has blurred vision and a new onset of confusion. The nurse should suspect that the client has developed which of the following imbalances?

​Respiratory alkalosis