Fundamentals practice A

A nurse is preparing to transfer a client who has right-sided weakness from the bed to a chair. In what order should the nurse take the following actions to assist the client?

- The first action the nurse should take is to assess the client to determine if he can bear weight and assist with his transfer. -Next, the nurse should position the chair on the side of the bed closest to the client's stronger side for easy access. -Next, the nurse should have the client sit and dangle his feet at the bedside to allow him to adjust to sitting up and prevent dizziness when transferring. -Finally, the nurse should use the stand-and-pivot technique to move the client to the chair.

A nurse is preparing a heparin infusion for a client who was hospitalized with deep-vein thrombosis. The order reads: 25,000 units of heparin in 250 mL of 0.9% sodium chloride to infuse at 800 units/hr. At what rate should the nurse set the infusion pump? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

8 mL

A nurse is administering an otic medication to an older adult client. Which of the following actions should the nurse take to ensure that the medication reaches the inner ear? A.Press gently on the tragus of the client's ear. B.Move the client's auricle down and back toward her head. C.Pack a small piece of cotton deep into the client's ear canal. D. Tilt the client's head backward for 5 min.

A

A nurse in a clinic is caring for a middle adult client who states, "The doctor says that, since I am at an average risk for colon cancer, I should have a routine screening. What does that involve?" Which of the following responses should the nurse make? A."You should have a fecal occult blood test every year." B."I'll get a blood sample from you and send it for a screening test." C. "The recommendation is to have a sigmoidoscopy every 10 years." D. "Beginning at age 60, you should have a colonoscopy."

A Colorectal cancer screening for clients at average risk begins at age 50. One option for screening is a fecal occult blood test annually.

A nurse is evaluating a client's use of a cane. Which of the following actions should the nurse identify as an indication of correct use? A. The client holds the cane on the stronger side of her body. B. The client moves her stronger limb forward with the cane. C. When walking, the client moves the cane 46 cm (18 in) forward. D .The top of the cane is parallel to the client's waist.

A The client should hold the cane on the stronger side of her body to increase support and maintain alignment.

A nurse is planning to insert a peripheral IV catheter for an older adult client. Which of the following actions should the nurse plan to take? A.Place the client's arm in a dependent position. B.Initiate IV therapy in the veins of the hand. C.Insert the catheter at a 45° angle. D.Shave excess hair from the insertion site.

A The nurse should place the client's arm in a dependent position because the veins will dilate due to gravity.

A nurse is reviewing practice guidelines with a group of newly licensed nurses. Which of the following interventions should the nurse include that is within the RN scope of practice? A .intiate enteral feeding through gastronomy B. insert implanted port C. close lacerations w sutures D. place an endotracheal tube

A. It is within the RN scope of practice for nurses to initiate enteral feedings through nasoenteric, gastrostomy, and jejunostomy tubes.

A nurse is assessing an older adult client's risk for falls. Which of the following assessments should the nurse use to identify the client's safety needs? (Select all that apply.) A. Appearance of bulbar conjunctivae B. Pupil clarity C. Lacrimal apparatus D. Visual fields E. visual acuity

B, D, E

A charge nurse is discussing the responsibility of nurses caring for clients who have a Clostridium difficile infection. Which of the following information should the nurse include in the teaching? A.Use alcohol-based hand sanitizer when leaving the client's room. B.Clean contaminated surfaces in the client's room with a phenol solution. C. Assign the client to a room with a negative air-flow system. D. Have family members wear a gown and gloves when visiting.

D Nurses are responsible for ensuring that family members wear a gown and gloves to prevent the transmission of Clostridium difficile spores. Caregivers must also wear gowns and gloves.

A nurse is reviewing a client's fluid and electrolyte status. Which of the following findings should the nurse report to the provider? A. Sodium 143 mEq/L B. Creatinine 0.8 mg/dL C. BUN 15 mg/dL D. Potassium 5.4 mEq/L

D. The value is above the expected reference range and the nurse should report this finding. This client is at risk for dysrhythmia

A nurse is caring for a client who is postoperative and refuses to use an incentive spirometer following major abdominal surgery. Which of the following is the nurse's priority action? A. Request that a respiratory therapist discuss the technique for incentive spirometry. B. Document the client's refusal to participate in health restorative activities. C. Administer a pain medication to the client. D. Determine the reasons why the client is refusing to use the incentive spirometer.

D. The first action the nurse should take when using the nursing process is to assess the client; therefore, the priority action is for the nurse to determine why the client is refusing the treatment.

A nurse is responding to a call light and finds a client lying on the bathroom floor. Which of the following actions should the nurse take first?

assess client for injuries -The first action the nurse should take when using the nursing process is to assess the client for injuries.

what type of precaution is the flu?

droplet

A nurse is caring for a client who has a prescription for 5 units of regular insulin and 10 units of NPH insulin to mix together and administer subcutaneously. Determine the correct order of steps for this procedure. (Move the steps into the box on the right, placing them in the order of performance.

1. The nurse should first inject air into the vial of NPH without touching the needle to the solution. 2. inject air into the vial of regular insulin, and then withdraw the correct amount of the regular insulin. 3.Finally, the nurse should insert the needle into the NPH insulin vial and withdraw the correct amount of NPH insulin.

A nurse is caring for a client who requires a 24-hr urine collection. Which of the following statements by the client indicates an understanding of the teaching? A."I flushed what I urinated at 7:00 a.m. and have saved all urine since." B."I had a bowel movement, but I was able to save the urine." C."I drink a lot, so I will fill up the bottle and complete the test quickly." D."I have a specimen in the bathroom from about 30 minutes ago."

A For a 24-hr urine collection, the client should discard the first voiding and save all subsequent voidings.

A nurse is assisting a client who is postoperative with the use of an incentive spirometer. Into which of the following positions should the nurse place the client? A. Semi-Fowler's B. Side-lying C. Trendelenburg D. Supine

A Positioning the client in semi-Fowler's or high-Fowler's position allows for maximum expansion of the lungs.

A nurse is caring for a client receiving fluid through a peripheral IV catheter. Which of the following findings at the IV site should the nurse identify as infiltration? A. Skin blanching B. Warmth C. Purulent exudate D. Bleeding

A Skin blanching, edema, and coolness at the IV site indicate infiltration

A nurse is assessing a client's readiness to learn about insulin administration. Which of the following statements should the nurse identify as an indication that the client is ready to learn? A. "I can concentrate best in the morning." B. "I'm wondering why I need to learn this." C. "It is difficult to read the instructions because my glasses are at home." D. "You will have to talk to my wife about this."

A. The client's statement indicates a readiness to learn because he is verbalizing the best time for him to learn.

A nurse is preparing to administer multiple medications to a client who has an enteral feeding tube. Which of the following actions should the nurse plan to take? A. flush w 15 mL B. push syringe when feeling resistance C. dissolve each med D. draw meds up together

A. The nurse should flush the feeding tube with 15 to 30 mL of sterile water before administration and between each medication. The nurse should flush the feeding tube with 30 to 60 mL of sterile water following the administration of the last medication.

A nurse is teaching an older adult client who is at risk for osteoporosis about beginning a program of regular physical activity. Which of the following types of activity should the nurse recommend? A. Walking briskly B. Performing isometric exercises C. Riding a bicycle D. Engaging in high-impact aerobics

A. Weight-bearing exercises are essential for maintaining bone mass, which helps to prevent osteoporosis. Walking engages older adult clients in this preventive and therapeutic strategy.

A nurse is caring for a client who has a prescription for wound irrigation. Which of the following actions should the nurse take? A. Cleanse the wound from the center outward. B. Warm the irrigation solution to 40.5° C (105° F). C. Use a 20-mL syringe to irrigate the wound. D. Wear sterile gloves when removing the old dressing.

A. The nurse should clean the wound from the center outward to prevent introduction of micro-organisms from the outer skin surface.

A nurse in a long-term care facility is planning to perform hygiene care for a new resident. Which of the following assessment questions is the nurse's priority before beginning this procedure? A."At what temperature do you prefer your bath water?" B. "Are you able to help with your hygiene care?" C. "When do you usually bathe, in the morning or in the evening?" D. "Do you prefer a bath or a shower?"

B

A nurse is admitting a client who has an abdominal wound with a large amount of purulent drainage. Which of the following types of transmission precautions should the nurse initiate? A. Protective environment B. Contact precautions C. Droplet precautions D. Airborne precautions

B Major wound infections require contact precautions, which mean the nurse should admit the client to a private room. All caregivers should wear a gown and gloves during direct contact with this client.

A nurse manager is overseeing the care on a unit. Which of the following situations should the nurse manager identify as a violation of HIPAA guidelines? A. A nurse who is caring for a client reviews the client's medical chart with the nursing student who is working with the nurse. B. A nurse asks a nurse from another unit to assist with her documentation. C. A nurse who is caring for a client returns a call to the client's durable power of attorney for health care designee to discuss the client's care. D. A nurse discusses a client's status with the physical therapist that is caring for the client at the client's bedside.

B Only health care professionals directly caring for a client may access medical information; therefore, this is a violation of HIPAA guidelines.

A nurse is assessing a client who has been on bed rest for the past month. Which of the following findings should the nurse identify as an indication that the client has developed thrombophlebitis? A. Bladder distention B. Calf swelling C. Diminished bowel sounds D. Decreased blood pressure

B Swelling, redness, and tenderness in a calf muscle are manifestations of thrombophlebitis, a common complication of immobility.

A nurse is completing an admission assessment for a client who reports vomiting and diarrhea for the past 3 days. Which of the following assessment findings should the nurse expect? A. Neck vein distention B. Rapid heart rate C. Urine specific gravity 1.010 D. Blood pressure 144/82 mm Hg

B Tachycardia indicates fluid-volume deficit, which is an expected finding for a client who has had vomiting and diarrhea for 3 days.

A nurse is reviewing protocol in preparation for suctioning secretions from a client who has a new tracheostomy. Which of the following actions should the nurse plan to take? A. adjust the wall suction apparatus to a pressure of 170 mm Hg. B. Select a suction catheter that is half the size of the lumen. C. Place the end of the suction catheter in water-soluble lubricant. D. Use a resuscitation bag with 80% oxygen prior to the procedure.

B The nurse should select a suction catheter that is half the size of the lumen to prevent hypoxemia and trauma to the mucosa.

A nurse is caring for a client who is having difficulty breathing. The client is lying in bed with a nasal cannula delivering oxygen. Which of the following interventions should the nurse take first? A. Administer a bronchodilator. B. Assist the client to an upright position. C. Increase the humidity in the client's room. D. Suction the client's airway.

B When providing client care, the nurse should first use the least invasive intervention. Therefore, the nurse should elevate the head of the client's bed to the semi-Fowler's or high Fowler's position to facilitate maximal chest expansion. Sitting upright improves gas exchange and prevents pressure on the diaphragm from abdominal organ

A nurse is caring for a client who has terminal liver cancer. Which of the following statements should the nurse identify as an indication that the client is experiencing spiritual distress? A."Where is my daughter at a time like this?" B. "What could I have done to deserve this illness?" C. "I blame medical science for not curing me." D. "Will I ever begin to feel in charge of my life again?"

B. The client's terminal illness might prompt him to review his life and question its meaning. A manifestation of the client's spiritual distress is asking why this illness is happening to him.

A nurse is caring for a client who has tuberculosis. Which of the following actions should the nurse take? (Select all that apply.) A.Wear gloves when assisting the client with oral care. B.Place the client in a room with negative-pressure airflow. C. Use antimicrobial sanitizer for hand hygiene. D.Limit each visitor to 2-hr increments. E. Wear a surgical mask when providing client care.

B. The nurse should place the client in a room with negative-pressure airflow to meet the requirements of airborne precautions. A. The nurse should wear gloves when assisting with oral care to meet the requirements of standard precautions, which the nurse must adhere to for all clients regardless of their diagnosis. The nurse should wear gloves whenever her hands might come in contact with a client's body fluids, such as saliva, and the mucous membranes in the mouth. C. the nurse should use antimicrobial sanitizer for routine hand hygiene when caring for a client who has tuberculosis. The nurse should also wash her hands with soap and water when her hands have visible soiling.

A nurse is preparing to administer an injection of an opioid medication to a client. The nurse draws out 1 mL of the medication from a 2 mL vial. Which of the following actions should the nurse take? A.Notify the pharmacy when wasting the medication. B.Lock the remaining medication in the controlled substances cabinet. C.Ask another nurse to observe the medication wastage. D.Dispose of the vial with the remaining medication in a sharps container.

C A second nurse must witness the disposal of any portion of a dose of a controlled substance.

A nurse is caring for a client who asks about the purpose of advance directives. Which of the following statements should the nurse make? A. "They allow health care personnel in the emergency department to stabilize a client's condition." B. "They allow the court to overrule an adult client's refusal of medical treatment." C. "They indicate the form of treatment a client is willing to accept in the event of a serious illness." D. "They permit a client to withhold medical information from health care personnel."

C Advance directives include a living will, which permits the client to direct treatment in the event of a terminal illness

A nurse in a surgical suite notes documentation on a client's medical record that he has a latex allergy. In preparation for the client's procedure, which of the following precautions should the nurse take? A. Wear hypoallergenic latex gloves that contain powder. B. Ensure sterilization of nondisposable items with ethylene oxide. C. Wrap monitoring cords with stockinette and tape them in place. D. Cleanse latex ports on IV tubing with chlorhexidine before injecting medication.

C Many monitoring devices and cords contain latex. The nurse should prevent any contact of these cords and devices with the client's skin by covering them with a nonlatex barrier material, such as stockinette, and using nonlatex tape to secure them.

A nurse is planning an education session for an older adult client who has just learned that she has type 2 diabetes mellitus. Which of the following strategies should the nurse plan to use with this client? A.Keep the learning session private and one-on-one. B.Expect the client to have difficulty understanding the information. C.Allow extra time for the client to respond to questions. D.Avoid references to the client's past experiences.

C Older adult clients often process information at a slower rate than younger clients; therefore, the nurse should plan for extra time to allow the client to ask questions and absorb the information.

A nurse is caring for a client who requires an NG tube for stomach decompression. Which of the following actions should the nurse take when inserting the NG tube? A. Apply suction to the NG tube prior to insertion. B. Remove the NG tube if the client begins to gag or choke. C. Have the client take sips of water to promote insertion of the NG tube into the esophagus. D. Position the client with the head of the bed elevated to 30° prior to insertion of the NG tube.

C Taking sips of water as the NG tube passes through the oropharynx will close the epiglottis over the trachea and prevent the tube's passage into the trachea.

A nurse is reviewing a client's medication prescription, which reads, "digoxin 0.25 by mouth every day." Which of the following components of the prescription should the nurse question? A.The frequency B.The medication C.The dose D.The route

C The dose is not complete. The number 0.25 should be followed by a unit of measurement, such as mg, to clarify the amount the nurse should administer.

A nurse is providing care to four clients. Which of the following situations requires the nurse to complete an incident report? A. A nurse administers a medication to a client 30 min before the dose is due. B. A nurse tied a client's restraint straps to the moveable part of the bed frame. C. A client who has an IV infusion pump receives an additional 250 mL of IV fluid. D. An assistive personnel placed a surgical mask on a client who has tuberculosis before transporting her to radiology.

C The nurse should complete an incident report if an IV infusion pump malfunctions to assist in compiling information for risk management to determine actions to take to prevent further similar incidents.

A nurse is preparing to administer 0.5 mL of oral single-dose liquid medication to a client. Which of the following actions should the nurse take A. Verify the dosage by measuring the liquid before administering it. B. Transfer the medication to a medicine cup. C. Gently shake the container of medication prior to administration. D. Place the client in a semi-Fowler's position prior to medication administration

C The nurse should gently shake the liquid medication to ensure the medication is mixed.

A nurse is caring for a client who requires bed rest and has a prescription for antiembolic stockings. Which of the following actions should the nurse take? A.Remove the stockings while the client is sitting in a reclining chair. B.Apply the stockings while the client's legs are in a dependent position. C.Remove the stockings at least once per shift. D.Apply the stockings so the creases are on the front side of the leg.

C The nurse should remove the stocking once per shift to check the client's circulation and skin integrity.

A nurse is planning care to improve self-feeding for a client who has vision loss. Which of the following interventions should the nurse include in the plan of care? A. thicken liquids on tray B. provide small hand held utensils C. use a clock pattern to describe food D. tell the client which foods to eat first

C. Describing the location of the food on the plate by using a clock pattern allows the client to have greater independence during meals.

A nurse has accepted a verbal prescription for three tenths of a milligram of levothyroxine IV stat for a client who has myxedema coma. How should the nurse transcribe the dosage of this medication in the client's medical record? A. .3 mg B. 0.30 mg C. 3/10 mg D. 0.3 mg

D

A nurse is talking with the partner of an older adult male client who has dementia. The client's partner expresses frustration about finding time to manage household responsibilities while caring for his partner. The nurse should identify that he is going through which of the following types of role-performance stress? A. Role conflict B. Role ambiguity C. Sick role D. Role overload

D

A nurse is caring for a client who has herpes zoster and asks the nurse about the use of complementary and alternative therapies for pain control. The nurse should inform the client that his condition is a contraindication for which of the following therapies? A. feverfew B. Biofeedback C. Aloe D. Acupuncture

D The nurse should inform the client that the use of acupuncture is contraindicated for a client who has herpes zoster, or any skin infection, to prevent an open portal on the skin's surface, which could increase the risk of further infection.

A nurse is caring for a client who has limited mobility in his lower extremities. Which of the following actions should the nurse take to prevent skin breakdown A.Place the client in high-Fowler's position. B. Massage reddened areas with unscented lotion. C. Increase the client's intake of carbohydrates. D. Have the client use a trapeze bar when changing position.

D By using a trapeze bar to assist with repositioning and transferring, the client avoids the friction and shearing that result from sliding up and down in bed. Shearing is a risk factor for pressure-ulcer development.

A nurse is assessing an adult client who has been immobile for the past 3 weeks. The nurse should identify that which of the following findings requires further intervention? A.Lower-extremity pulse strength of 2+ B. A bowel movement every other day C. Fluid intake of 3,000 mL per day D. Erythema on pressure points

D Erythema on pressure points requires prompt relief of pressure and additional measures to protect the skin from further breakdown.

A nurse is caring for a client who has had his diet prescription changed to a mechanical soft diet. Which of the following food items should the nurse remove from the client's breakfast tray? A.pancakes B. bananas C.juice D. egg

D Evidence-based practice indicates the nurse should remove fried eggs from the client's tray. Fried eggs are not a part of a mechanical soft diet. Eggs that are poached or scrambled are an acceptable replacement for this item.

A nurse is giving discharge instructions to a client who will require oxygen therapy at home. Which of the following statements should the nurse identify as an indication that the client understands how to manage this therapy at home? A. "I'll make sure that, when my friend comes by, she smokes at least 6 feet away from my oxygen tank." B. "I'll use a woolen blanket if I get chilly while I'm using my oxygen." C. "I'll lay my oxygen tank down on the floor when the grandchildren visit so they don't knock it over." D. "I'll check the wires and cables on my TV to make sure they are in good working order."

D Oxygen is a highly flammable gas. The client should make sure any electrical equipment in the room where she is using supplemental oxygen is functioning properly so it does not create any electrical sparks.

A nurse is caring for a client who is reporting difficulty falling asleep. Which of the following measures should the nurse recommend? A. Drink a cup of hot cocoa before bedtime. B. Exercise 1 hr before going to bed. C. Reflect on the day's activities before going to bed. D. Use progressive relaxation techniques at bedtime.

D Progressive relaxation promotes sleep by decreasing stress and reducing muscle tension.

A nurse manager is preparing to review medication documentation with a group of newly licensed nurses. Which of the following statements should the nurse manager plan to include in the teaching? A."Use the abbreviation SC when indicting an injection." B."Delete the space between the numerical dose and the unit of measure." C. "Write the letter U when noting the dosage of insulin." D. "Use the complete name of the medication magnesium sulfate."

D The Institute for Safe Medication Practices designates that nurses and providers write the complete medication name magnesium sulfate when documenting medications to avoid any misinterpretation of MgSO4 as MSO4, which means morphine sulfate

A nurse is caring for a client who has an NG tube and is receiving intermittent feedings through an open system. Which of the following actions should the nurse take first? A. Make sure the enteral formula is at room temperature. B.Wipe the top of the formula can with alcohol. C.Rinse the feeding bag with water between feedings. D. Tell the client to keep the head of the bed elevated at least 30°.

D The first action the nurse should take when using the airway, breathing, circulation approach to client care is to prevent aspiration of the enteral formula; therefore, the priority intervention is to keep the head of the bed elevated at least 30° to prevent reflux of the formula backward into the esophagus.

A nurse is using an open irrigation technique to irrigate a client's indwelling urinary catheter. Which of the following actions should the nurse take? A.Instill 15 mL of irrigation fluid into the catheter with each flush. B. Perform the irrigation using a 20-mL syringe. C. Place the client in a side-lying position. D. Subtract the amount of irrigant used from the client's urine output.

D The nurse should calculate the fluid used for irrigation and subtract it from the client's total urinary output.

A nurse is administering IV fluid to an older adult client. The nurse should perform which priority assessment to monitor for adverse effects? A. Measure urine output. B. Monitor serum electrolyte levels. C. Monitor blood pressure readings. D. Auscultate lung sounds.

D The priority assessment the nurse should make when using the airway, breathing, circulation approach to client care is auscultating lung sounds to monitor for fluid-volume excess, a complication of IV therapy. Manifestations of fluid volume excess include moist crackles heard in lung fields, dyspnea, and shortness of breath.

A nurse is lifting a bedside cabinet to move it closer to a client who is sitting in a chair. To prevent self-injury, which of the following actions should the nurse take when lifting this object? A. Use his back muscles for lifting. B. Bend at the waist. C. Keep his feet close together. D. Stand close to the cabinet when lifting it.

D. This action keeps the cabinet close to the nurse's center of gravity and decreases back strain from horizontal reaching.

A nurse is caring for a client who reports pain. When documenting the quality of the client's pain on an initial pain assessment, the nurse should record which of the following client statements? A. "The pain makes me feel nauseous." B. "I'm having mild pain." C. "I notice that the pain gets worse after I eat." D. "The pain is like a dull ache in my stomach."

D. he client is describing the quality of the pain, which is how the pain feels in her own words.

A nurse is performing a Romberg's test during the physical assessment of a client. Which of the following techniques should the nurse use?

have client stand w arms and legs together -Romberg's test helps identify alterations in balance. The nurse should have the client stand with her arms at her sides and her feet together to observe her for swaying and a loss of balance.