Fundamentals Proctored Practice Part 1
A nurse is orienting a newly licensed nurse about documentation of a client's information in the electronic health record. Which of the following statements by the newly licensed nurse indicates understanding of the purpose of documentation? A. "Documentation is a communication tool for the interprofessional health care team." B. "Documentation provides informaition to the client about financial charges for care provided." C. "Documentation provides information for a client audit." D. "Documentation allows providers to monitor the nurse's activities."
A. "Documentation is a communication tool for the interprofessional health care team." Documentation provides information to facilitate communication among members of the interprofessional health care team in making client-centered decisions, planning appropriate therapies and evaluating a client's progress.
A nurse is planning to discharge a client who has quadriplegia to his home. The nurse suggests that the family might need respite care services. When a family member asks how respite care can help, which of the following responses should the nurse provide? A. "Respite care allows the primary caregiver time away from day-to-day care responsibilities." B. "Respite care provides holistic support and care for a client who is terminally ill." C, "Respite care helps relieve pain and promote comfort." D. "Respite care is a continuation of psychological support after a family member dies."
A. "Respite care allows the primary caregiver time away from day-to-day responsibilities." A client who has quadriplegia requires support for many activities of daily living. Primary caregivers need time to meet their own personal needs as well. Respite care allows the primary caregiver time away from day-to-day responsibilities for the client.
A nurse is assisting with the admission of a client to an inpatient unit. Which of the following sources of information should the nurse rely on for accurate information about the client? A. Client concerns B. Family information C. Medical history D. Progress note
A. Client concerns Information the nurse obtains directly from the client is generally the most accurate and provides the best information available
A newly licensed nurse is applying prescribed wrist restraints on a client. Which of the following actions should the nurse take? A. Secure the restraints using a quick -release tie B. Ensure four fingers fit under the restraints to prevent constriction C. Secure the restraints to the lowest bar of the side rail D. Anticipate removing the restraints every 4 hr
A. Secure the restraints using a quick -release tie The nurse should secure the restraints using a quick-release tie for easy removal in an emergency
A nurse is providing discharge teaching to a client who has a new prescription for a metered dose inhaler (MDI). Which of the following instructions should the nurse include in the teaching? A. Shake the inhaler for 3-5 seconds. B. Rinse the mouth with mouthwash after inhaling this medication. C. Wait 2 min between inhalations. D. Press down twice on the MDI canister.
A. Shake the inhaler for 3-5 seconds. After fully inserting the canister into the inhaler, the client should shake it vigorously for 3-5 seconds to ensure he mixes the medication thoroughly.
A nurse is performing tracheostomy care for a client and suctioning to remove copious secretions. Which of the following actions should the nurse take? A. Suction 2-3 times with 60 second pauses between passes B. Perform chest physiotherapy prior to suctioning C. Lubricate suction catheter tip with sterile saline D. Hyperventilate the client on 100% oxygen prior to suctioning
A. Suction 2-3 times with 60 second pauses between passes Copious secretions may requires several passes of the suction catheter. An interval of 60 seconds should be allowed between passes to prevent hypoxia.
A nurse is engaging in relationship counseling with a male client. Which of the following is a characteristic of men that the nurse should consider when beginning the nurse-client relationship? A. They are more direct when discussing issues B. They are likely to wait for others to initiate the conversation C. They tend to use more verbal communication D. They disclose more personal information
A. They are more direct when discussing issues Men focus on issues and discuss them more directly and readily than women do.
A nurse is teaching a client who has a new diagnosis of atopic dermatitis,. Which of the following statements should the nurse include in the teaching? A. "You will need to take the entire prescription of antibiotics even if your condition improves." B. "Your provider may recommend a daily antihistamine to help control your symptoms." C. "You should cleanse your mouth daily with a prescribed mouthwash." D. "Your provider will remove the lesions with solid carbon dioxide."
B. "Your provider may recommend a daily antihistamine to help control your symptoms." Atopic dermatitis is commonly related to an allergic reaction; therefore, it is appropriate to treat this condition with an antihistamine.
A nurse is caring for a client who has an NG tube. The nurse tests the pH of the secretions to determine if the tube is correctly placed. Which of the following readings should the nurse expect? A. 6.0 B. 4.0 C. 7.0 D. 8.0
B. 4.0 This is an acidic pH, which is consistent with gastric drainage. This indicates that the NG tube is correctly placed.
A nurse is caring for a client of Chinese heritage. Which of the following actions should the nurse take to demonstrate cultural competence? A. Make sure the dietary department does not serve the client pork. B. Ask the client's permission to add ice to drinking water. C. Maintain direct eye contact with the client. D. Place a hand on the client's head.
B. Ask the client's permission to add ice to drinking water. Many clients of Chinese heritage prefer beverages without ice.
A nurse is planning care for a client who has decreased LOC. The client is receiving continuous enteral feedings via gastrostomy tube due to an inability to swallow. Which of the following is the priority action by the nurse? A. Observe the client's respiratory status. B. Elevate the head of the client's bed 30-45 degrees C. Monitor intake and output every 8 hr D. Check residual volume every 4-6 hr
B. Elevate the head of the client's bed 30-45 degrees A client who has decreased LOC and an inability to swallow is at risk for aspiration. Laying flat also increases this risk. The priority action by the nurse is to keep the head of the bed elevated 30-45 degrees to promote gastric emptying and reduce risk for aspiration.
A nurse is developing a therapeutic relationship with a client. The nurse should perform which of the following actions during the working phase of a therapeutic relationship? A. Determine the reason the client sought care B. Instruct the client about methods to achieve goals C. Discuss the client's new skill sets D. Review the client's demographic information
B. Instruct the client about methods to achieve goals Instructing the client about methods to achieve goals describes the working phase, when the nurse and the client work together to solve problems and accomplish goals
A nurse is giving a presentation about client confidentiality to a group of newly licensed nurses. Which of the following actions is an example of a violation of confidentiality? A. Discussing a client's surgical procedure with the nurse manager B. Reporting laboratory findings to a member of the client's family C. Notifying the provider of physical examination findings D. Identifying the client by name when making a referral for home health services
B. Reporting laboratory findings to a member of the client's family Confidentiality is the nondisclosure of information except to an authorized person, that is, someone involved in the client's care or someone the client has given permission for informing. Reporting laboratory findings to a family member without the client's permission violates client confidentiality.
A client tells the nurse that he suspects that he grinds his teeth at night. The nurse should explain that the client should see a dentist for this problem, which should she document as as which of the following disorders? A. Xerostomia B. Halitosis C. Bruxism D. Sordes
C. Bruxism Bruxism, a clenching or grinding of the teeth during sleep, can damage the teeth. A Dentist can provide a custom-fitted, comfortable dental appliance to protect the teeth during sleep.
A nurse is assessing for cyanosis in a client who has dark skin. Which of the following sites should the nurse examine to identify cyanosis in the client? A. Pinnae of the ears B. Dorsal surface of the hand C. Conjunctivae D. Dorsal surface of the foot
C. Conjunctivae To assess the skin color changes in clients who have dark skin, the nurse should examine body areas with minimal pigmentation, such as the sclerae, soles of feet, conjunctivae and mucous membranes.
A nurse is measuring a client for knee-high antiembolic stockings to help prevent venous stasis. Which of the following actions should the nurse take? A. Measure from the heel to the gluteal fold. B. Measure the length of the feet. C. Measure fro mthe heel to the popliteal space. D. Measure the ankle circumference.
C. Measure fro mthe heel to the popliteal space. If the stocking is too short, it could impair circulation at its upper end. If it is too long, it can bunch together, which would cause pressure and irritate the skin. Measuring the length from the feet to the popliteal space helps the nurse identify the right size stockings for the client's legs.
A nurse in a long-term care facility is caring for an older client who has dementia and begins to have frequent episodes of urinary incontinence. After the provider determines no medical cause for the client's incontinence, which of the following interventions should the nurse initiate to manage this behavior? A. Remind the client to tell the nurse when he has to urinate B. Use adult diapers to prevent frequent clothing changes C. Take the client to the bathroom every 2 hr D. Request a prescription for an indwelling urinary catheter
C. Take the client to the bathroom every 2 hr By assisting the client to the bathroom every 2 hr, the staff establishes a regular pattern of toileting, and the client learns to trust that the staff places value on his bladder-training needs. He also learns a physical pattern that promotes bladder control.
A nurse is assisting a client who has received crutches in an urgent care center following a foot injury. Which of the following statements should the nurse identify as an indication that the client needs further teaching? A. "I will keep spare crutch tips handy." B. "I will bear the weight of my body on my hands." C. "I will inspect my crutches every day for signs of wear." D. "I have a set of my brother's crutches in my basement I can also use."
D. "I have a set of my brother's crutches in my basement I can also use." The client should not use crutches that belong to someone else. The client's crutches must fit his body dimensions, not someone else's.
A nurse is instructing a young adult client about healthful sleep habits. Which of the following statements should the nurse identify as an indication that the client needs further teaching? A. "I don't take naps throughout the day." B. "I go to bed and get up routinely at the same time each day." C. "I have a small snack and take a bath before going to bed each day." D. "I watch television until I fall asleep at night."
D. "I watch television until I fall asleep at night." The client should minimize environmental stimuli just before bedtime, because it can interfere with falling asleep.
A nurse is reviewing a client's prescription for 1000 mL of 5% dextrose in water IV to infuse over 8 hr. At 1400, the nurse observes that there is 500 mL of solution remaining in the client's current IV bag. At what time should the nurse administer the next bag of IV solution? A. 1500 B. 1600 C. 1700 D. 1800
D. 1600 The IV will infuse at 125 mL/hr. The next bag of IV solution will need to be administered at 1800.
A nurse is admitting a client who has partial hearing loss. Which of the following is the priority action by the nurse? A. Speak using his usual tone of voice. B. Stand directly in front of the client C. Rephrase statements the client does not hear. D. Determine if the client uses hearing aids.
D. Determine if the client uses hearing aids. The first action by the nurse should take using the nursing process is to assess the client. The nurse should find out if the client has hearing aids and whether they are in place and functioning.
A nurse in a long-term care facility is observing an assistant personnel changing the linen for a client who has fecal incontinence. Which of the following actions indicates that the AP understands the principles of infection control? A. Shakes the soiled linen to remove any toilet paper remnants B. Places the soiled linen on the floor before bagging it C. Holds the soiled linen against her body while carrying it to the linen bag D. Places clean linen that touched the floor in the soiled linen bag
D. Places clean linen that touched the floor in the soiled linen bag Linen that touches the floor or the AP drops requires laundering.
A nurse is admitting a client who has hepatitis C. Which of the following precautions should the nurse implement? A. Droplet B. Contact C. Airborne D. Standard
D. Standard Hepatitis C is a blood-borne pathogen that is commonly spread by needle stick injury, sharing of IV drug paraphernalia and sexual contact. The nurse should implement standard precautions when in contact with blood, body fluids, broken skin and mucous membranes. The nurse should wear additional PPE if there is possible blood contact or a risk for splashes or sprays of blood or body fluids.
