Fundamentals Round 3

A nurse is conducting an admission interview with the client which of the following pieces of assessment information should the nurse collect during the introductory phase of the interview?

The client's level of comfort and ability to participate in the interview through established rapport

A nurse in an emergency department is caring for a client who reports developing severe right eye pain with a gritty sensation while sawing wood which of the following action should the nurse take first?

The nurse must collect data first so any information in regards to how the client went about first performing his first aid at the scene

A nurse on a surgical unit is receiving a client who had abdominal surgery from the post anesthesia care unit which of the following assessments should the nurse make first?

The nurse should apply the ABC priority setting framework when caring for this client the framework emphasizes and prioritizes having an open airway being able to breathe in adequate amounts of oxygen and circulating oxygen to the body's organs via the blood. The airway is the highest priority because oxygen exchange needs to occur

A nurse is caring for a client who requires a dressing change which of the following actions should the nurse take?

The nurse should clean the drain site from the center outward to avoid introducing microorganisms from the peripheral of the wound into the center of the wound

A nurse delegates to collection of a client's temperature to an assisted personnel (AP) the nurse notes in the documentation that the AP obtained the clients auxiliary temperature however the nurse wanted an oral temperature the nurse should identify that which of the following rights of delegation should have prevented this situation from occurring?

The situation could have been avoided if the right communication was given by the nurse to the AP the right communication entails providing clear concise instructions regarding the tasks including the objective limits and expectations A nurse is preparing a sterile field for a procedure the provider will perform at the client's bedside which of the following actions should the nurse take? Contamination occurs when the nurse holds any object that will be part of the sterile field below the waist or allows it to touch anything other than a sterile object. A nurse must hold the sterile drape above the waist and away from the body

A nurse is reviewing a client's laboratory results and notes a dub count of 3600 the nurse should identify those results as which of the following conditions?

Normal count for WBCS in the blood is 4500 to 11,000 Leukopenia occurs when there is a decrease in the production of WBCS this alteration places the client at an increased risk of infection

A charge nurse is observing a newly licensed nurse perform tracheostomy care for a client which of the following actions by the newly licensed nurse requires intervention?

Obtaining cotton balls for tracheostomy care because cottonballs particles can be aspirated into the tracheostomy opening possibly causing a tracheal Abscess the charge nurse should intervene for this action

A nurse is initiating seizure precautions for a client who has a seizure disorder which of the following pieces of equipment should the nurse have readily available at the client's bedside?

Oxygen equipment at the bedside would ensure for proper seizure precautions the nurse should be applying oxygen via mask or nasal canal to client who has experienced a seizure

A nurse is leading an education session with disposing of biohazardous materials which of the following instructions should the nurse include in the teaching?

Soiled linen should be placed in a single bag that is tightly secured to reduce the risk of transmission of microorganisms

A nurse is caring for a client who has a history of dysrhythmias upon entering the room the nurse discovers the client is unresponsive to verbal or painful stimuli has no respirations and is pulseless which of the following actions should the nurse take first?

Start chest compressions when there are several risks to a client safety the one posing the greatest threat is the highest priority so performing a cardio pulmonary resuscitation which starts with chest compressions followed by opening the airway and breathing for adults and pediatric clients evidence indicates a great survival rate with when chest compressions are started before a breath is initiated

A nurse is obtaining a capillary blood sample to determine a clients blood glucose levels the nurse prepares and punctures the clients finger for the procedure but does not obtain an adequate amount of blood which of the following actions should the nurse take?

Wrap the clients finger in a warm washcloth because this helps increase the blood flow to the client's finger

A nurse is caring for a client who is well hydrated and has no visible evidence of nutritional deficiency a laboratory result within the expected reference range for which of the following substances indicates adequate protein uptake and synthesis?

The nurse should identify that an albumin level within the expected reference range is an indication that there's adequate protein uptake and synthesis

A nurse is assessing a client who is unconscious family members are present and answer the nurses questions about the clients medical history the nurse should document this information as which of the following types of data?

This is a secondary source data because information provided by someone other than the client is secondary source data

A nurse is planning to administer pain medication to a client following abdominal surgery which of the following actions should the nurse take first?

Use the pain scale to determine the clients pain level

A nurse is providing discharge teaching to a client who does not speak the same language as the nurse the client's neighbor who speaks both the client's native language and the nurses arrives to drive the client home which of the following actions should the nurse take?

We must obtain the services of an interpreter because federal mandates require that a professional medical interpreter translate the clients health care information into the client's native language

A nurse on a rehabilitation unit is preparing to transfer a client who is unable to walk from my bed to a wheelchair which of the following techniques should the nurse use?

Place the wheelchair at a 45 degree angle to the bed by positioning the wheelchair at a 45 degree angle this allows the client to pivot lessening the amount of rotation required

A nurse in the emergency department is caring for a client who has abdominal trauma which of the following assessment findings should the nurse identify as an indication of hypovolemic shock?

Tachycardia due to the increased circulatory blood volume that occurs with internal bleeding the oxygen carrying capacity the blood is reduced so the body attempts to relieve the hypoxia by increasing the heart rate and cardiac output while increasing the respiratory rate

A nurse on a medical surgical unit observed smoke billowing from a client's room which of the following actions should the nurse take first?

The acronym RACE can help nurses remember the order of actions to take when there's a fire: rescue, activate, confine, and extinguish. so the first priority is rescuing or removing the client from the immediate danger evacuate the client

A nurse is teaching a client with lower extremity weakness how to use a four point crutch gait which of the following instructions should the nurse include in the teaching?

The client should keep three points on the ground at all times therefore he must be able to bear weight on both legs

A nurse is teaching a client who is using a patient controlled analgesia PCA pump to deliver morphine for pain management which of the following statements should the nurse identify as an indication that the client understands the instructions?

"I can use my transcutaneous electrical nerve stimulation unit while pushing the PCA button" the nurse should encourage the client to utilize nonpharmacological methods of pain management such as Transcutaneous electrical nerve stimulation TENS while using a PCA pump to reduce the amount of opioid dosing the client needs

A nurse is caring for a client who is post operative following a vaginal hysterectomy and asked for a drink her post operative diet prescription states clear liquids advanced diet as tolerated which of the following responses should the nurse make?

"I'm going to listen to your abdomen" a common reason clients experienced nausea and vomiting after surgery is delayed gastric emptying time or decreased peristalsis the nurse should auscultate the clients abdomen to determine the presence of bowel sounds before clear liquids can be administered

A nurse is assessing a client who has a sudden onset of severe back pain of unknown origin which of the following question should the nurse ask to encourage discussion with the client?

"What do you think caused the onset of your pain" the nurse is using an open ended question that allows the client to respond with a ride range of information by using more than a few words

what are the maslow's hierarchy of needs 5 levels of priority

1) physiological needs 2) safety and security needs 3) love and belonging needs 4) personal achievement and self esteem needs 5) achieving full potential and the ability to problem solve and cope with the life situations

A nurse is performing in neurological assessment of a client to promote safety during the examination the nurse stands nearby as the client follows the instructions for which of the following tests?

A Romberg test evaluates standard balance first with the clients eyes open and then with them closed the nurse should remain nearby because the client could fall during this test

A nurse is caring for a client who is having difficulty with muscle coordination following a head injury the nurse should suspect injury to which of the following areas of the brain?

A nurse should suspect an injury to the cerebellum if the client is experiencing difficulty controlling balance and coordination a client's movement can become uncoordinated unsure and clumsy following an injury to this part of the brain

a nurse is caring for a client who states that she does not want to get out of bed due to pain from arthritis which of the following actions should the nurse take?

Advise the client to perform range of motion exercises while in bed because performing range of motion exercises will help the client maintain mobility until her pain is under control and she is able to ambulate without excessive discomfort

A nurse is admitting a client who has measles which of the following types of transmission precautions should the nurse initiate?

Airborne precautions are required for clients who have infections that spread via droplet nuclei that are smaller than five microns in diameter including varicella tuberculosis and measles

A nurse is caring for a client who is producing large amounts of urine the nurse should document this finding as which of the following?

Diuresis or polyurea is the excretion of high volume of urine this condition has many causes including metabolic and hormonal imbalances and diuretic therapy for treating renal cardiovascular and pulmonary disorders

A nurse is inserting an Ivy catheter for a client that results in a blood spill on her glove hand the client has no documented bloodstream infection which of the following actions should the nurse take?

Carefully remove the gloves and proceed with hand hygiene because standard precautions required the use of gloves and hand hygiene and the care of all clients

A nurse is preparing to administer aid tubercule in skin test to a client after performing hand hygiene which of the following actions should the nurse take?

Circle the injection area with the pen because circling the area with the pen ensures the nurse will examine the correct site when reading the test 48 to 72 hours later

A nurse is caring for a client who has terminal pancreatic cancer when the client states it's devastating that I will not be here to see my child graduate the nurse should identify the decline is in which following stages of grief as defined by kuebler Ross?

Depression because during the depression stage the client has realized the full impact of the loss or impending death and might express hopelessness and despair

A nurse is preparing to administer a feeding via a gastrostomy tube to a client who had a stroke which of the following action should the nurse take prior to initiating the feeding?

Elevate the head of the clients bed see the clients who have brain injury are typically unable to swallow effectively and thus cannot protect their airway from aspiration the nurse should strive to prevent aspiration by elevating the head of the bed prior to initiating the feeding

A nurse is caring for an adult client who has an Ng tube in place and a prescription for continuous enteral feedings which of the following actions should the nurse perform to reduce the client's risk of aspiration?

Elevating the head of the bed to at least 30 degrees and preferably 45 degrees helps prevent gravitational reflux of gastric contents thereby decreasing the risk of aspiration

A new resident provider asked the charge nurse for an access code to review clients online records the resident is not scheduled to attend the facilities orientation computer class until next week which of the following actions should the nurse take?

Explain that it's against policy to share access codes and refer to the resident to a supervisor staff members should never have access codes and passwords or allow people who do not have their own access code to use the system allowing unauthorized access is a breach of federal guidelines for data security and client confidentiality

A nurse is teaching a group of older adults about expected age related changes which of the following statements by a group member indicates that the teaching has been effective?

I should expect my heart rate to take longer to return to normal after exercise as I get older because older adults experience decreased cardiac output which causes an increased pulse rate during exercise the pulse rate also takes longer to return to normal after exercise

A nurse is preparing to administer a partial dose of prefilled opioid analgesics parenterally to a client which of the following actions should the nurse plan to take?

Record the amount of medication wasted on the controlled substance inventory record because two nurses should sign the controlled substance inventory record to document the amount of medication wasted

A nurse at a screening clinic is assessing a client who reports a history of heart murmur related to an aortic valve stenosis at which of the following anatomical areas should the nurse place the stethoscope to auscultate the aortic valve?

the aortic valve is located in the second intercostal space to the right of the sternum aortic stenosis produces a mid-systolic ejection murmur that can be heard clearly at the aortic area with the client leaning forward

A nurse is explaining the use of written consent forms to a newly licensed nurse the nurse should ensure that a written consent form has been signed by which of the following clients?

A client who has a prescription for a transfusion of packed red blood cells because administration of blood is a procedure that carries risk therefore the client must sign a consent form prior to the procedure

A nurse is planning care for a group of clients receiving oxygen therapy which of the following clients should the nurse plan to see first?

A client who has heart failure and is receiving 100% oxygen via partial rebreather mask so the nurse should apply the safety and risk reduction priority setting framework which assigns priority to the factor or situation posing the greatest safety risk to the client the nurse should frequently check the bag on a rebreather mask to ensure it inflates properly if the bag is deflated the client will re breathe exhaled carbon dioxide instead of receiving the prescribed oxygen dose therefore the nurse should first see the client who has heart failure and is receiving 100% oxygen via the partial rebreather mask oxygen is a gas that can cause toxicity and is highly combustible and high concentrations of oxygen increases the risk for client injury .

A nurse is communicating with a group of clients about what to expect during the postoperative phase of total hip arthroplasty which of the following elements of communication process should the nurse identify as an evaluation of affective communication?

Feedback in verbal and nonverbal forms is evidence of successful communication

A nurse is caring for an adult client who communicates an unmet spiritual need which of the following client statements should indicate to the nurse that the client is experiencing spiritual distress?

God is punishing me for something" because spiritual distress is an impaired ability to integrate meaning and purpose in life through various means including belief systems and relationships so they think that the higher power is punishing the individuals for some behavior

A nurse is teaching a client how to self administer insulin which of the following actions should the nurse take to evaluate the client's understanding of the process within the psycho motor domain of learning?

Have the client demonstrate the procedure because having the client demonstrate the procedure provides the nurse the ability to evaluate the clients understanding within the cycle motor domain of learning

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 pill on the floor which of the following entries should the nurse enter into the client's medical record?

The nurse should document exactly what took place to provide an accurate factual amount of the evidence so thus the nurse should document the client's actions in the medical record by stating that the client through the medication on the floor

a nurse is caring for a client who Requires ventilatory assistance with breathing following a motor vehicle crash the nurse should suspect an injury to which of the following parts of the brain?

The nurse should identify an injury to the medula and pons of the brainstem for a client who is experiencing difficulty with breathing the brainstem serves as the respiratory Control Center and the neurological injury can impair the center inhibit respiratory effort

A nurse is caring for a client who reports feeling a pop after coughing without properly splinting an abdominal incision on assessment the nurse knows that the client's wound has eviscerated which of the following actions should the nurse take select all that apply?

The nurse should place the client in a supine position with the hips and knees flex this position can help to prevent further tearing of the incision and wound evisceration by lessening tension on the wound next the nurse should cover the wound and intestine with a sterile moistened dressing it should be moistened with .9% sodium chloride to prevent further contamination of the wound and to keep protruding intestine from drying out next the nurse should monitor the client for any manifestations of shock the nurse should monitor for increased heart rate and respiratory rate changes in blood pressure or mentation and cool or clammy skin

A nurse is applying antiembolitic stockings for a client who has a history of deep vein thrombosis which of the following actions should the nurse take when applying the stockings?

The nurse should turn the stocking inside out up to the clients heal to make the application of the stocking easier and cause fewer constrictive wrinkles

A nurse is preparing to assist an older adult client with ambulation following bed rest for three days which of the following actions should the nurse take to decrease the risk of fall?

The nurse should use a gait belt to keep the client center of gravity midline and decrease the risk of a fall

A nurse is performing a physical examination of for a client to evaluate the client's skin moisture that nurse should use which of the following techniques?

The nurse should use palpation because with palpation the nurse uses touch to help detect unusual or expected sensations including texture temperature masses or moisture