Fundies practice assessment
A mass is caring for a client who has fallen while getting out of bed and states, "I'm okay! I guess I should have called for help to the bathroom." After assessing the client, The nurse notifies the provider. Which of the following documentation should the nurse include in the client's medical record?
"The provider was notified."
A nurse at an extended care facility is instructing a class of assistive personal (AP) about client use of assistive devices during ambulation. Which of the following instructions should the nurse give the APs about the client's use of a cane?
"When the client moves, he should move the cane forward first"
A nurse is administering several medications via a client's gastrostomy tube. At which of the following time should the nurse and stall 15 to 30 mL of warm water?
After each medication Prior to administering each medication After giving multiple medications
A nurse is admitting a client who reports anorexia and experiencing malnutrition. Which of the following laboratory findings should the nurse expect to be altered?
Albumin
A nurse is preparing to perform hand hygiene. Which of the following actions should the nurse take?
Apply 4 to 5 mL of liquid soap to the hands
A nurse is caring for a client who has urinary incontinence. Which of the following actions should the nurse implement to prevent the development of skin breakdown?
Apply a moisture barrier ointment to the client's skin
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 caring for a client who experience a lacerated spleen and has been on bed rest for several days. The nurse auscultates decreased breath sounds in the lower lobes of both lungs. The nurse should realize that this finding is most likely an indication of which of the following conditions?
Atelectasis
A nurse is caring for a client who is immobile. Which of the following actions is the priority for the nurse to include in the client's plan of care?
Auscultate breath sounds at least every 2 hr.
A nurse is preparing to answer and IV catheter for a client and has selected the insertion site. Place the following steps and the order in which the nurse should perform them.
Cleanse the site with an antiseptic swap Apply a tourniquet or BP cuff Dilate the vein Insert the catheter Flush the catheter
The nurse is administering an enteral feeding through a client's NG tube. Which of the following actions should the nurse take?
Cleanse the top of the can of formula with an alcohol wipe
The nurses can for a client who has a wound infection. Which of the following action should the nurse take on obtaining a wound drainage specimen for culture?
Cleanse the wound with 0.9% sodium chloride saline irrigation before obtaining the specimen
A nurse is caring for a client who is postoperative following abdominal surgery. The surgeon initially prescribes a clear liquid diet. Which of the following item should the nurse include on the clients lunch tray?
Cranberry juice
A nurse is caring for a client who requests prescription pain medication. Which of the following actions should the nurse perform first?
Determine the location of the pain
A nurse is planning care for client to his postoperative. Which of the following statements about pain management should the nurse consider when implementing client care?
Each client's expression of may may be different and individualized Pain level and pain tolerance can be assessed using a scale from 0 to 10 Patient-controlled analgesia (PCA) offers a constant level of opioids within therapeutic range
A nurse is preparing to administer 3 liquid medications to a client who has an NG feeding tube with a continuous enteral feedings. Which of the following actions should the nurse take?
Flush the NG feeding tube with 30 mL of water immediately following medication administration
A nurse is attending a social event when another guest coughs weakly once, grasped his throat with his hands, and cannot talk. Which of the following actions should the nurse take?
Perform the Heimlich maneuver
A nurse in a long term care facility is observing an assistant personnel (AP) changing the linen for a client who has fecal incontinence. Which of the following actions indicate that the AP understands the principles of infection control?
Places clean linen that touched the floor in the soiled linen bag
A nurse is caring for a client who needs a stool specimen collected. Which of the following actions should the nurse take when obtaining the specimen?
Send specimen container immediately to the lab
A nurse is caring for a client and identifies and infiltration at the IV catheter site. Identify the order the nurse should perform the following actions.
Stop the infusion Remove the IV catheter Apply a sterile dressing Elevate the extremity Apply a warm or cold compresses
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 caring for a client who is postoperative. The nurse should base her pain management interventions primarily on which of the following methods of determining the I intensity of the client's pain?
The client's self-report of pain severity
A nurse is providing oral care for client who is immobile. Which of the following actions should the nurse take?
Turn the client on his side before starting oral care
A nurse on a medical unit is caring for a client who suddenly becomes confused and drowsy. Additional data includes pulse a 100/min, respiratory rate 24/min, BP 132/76 mm Hg, and temperature 36.8°C (98.2°F). Which of the following actions should the nurse perform?
complete a neurological check
A nurse needs to lift a box and a supply room. Which of the following actions show the nurse take to prevent an injury due to lifting?
keep the box close to his body as he lifts
A nurse is preparing to exit the Room of a client who has (MRSA) in a draining wound. Identify the sequence the nurse should follow before leaving the client's room. (Move the steps into the box on the right, placing them in order of performance. Use all the steps.)
remove the gloves remove eyewear remove gown remove facemask performe hand hygiene
A nurse is assessing a client who is experiencing prostatic hypertrophy. Which of the following findings associated with urinary retention should the nurse expect? (Select all that apply)
report of feeling pressure tenderness over the symphysis pubis distended bladder voiding 30 mL frequently
The nurses providing discharge teaching to a client has a new prescription for a metered dose inhaler (MDI). Which of the following instruction should the nurse include in the teaching?
shake the inhaler for 3 to 5 seconds
A nurse is administering 1 mg hydromorphone IV to a client. The available dose is 2mg/mL. What should the nurse do with the remaining medication?
waste the medication in the presence of another nurse
A nurse is teaching a client about foods that are included on a clear liquid diet. Which of the following food choices made by the client indicates a need for further teaching?
yogurt
The nurses strikes a female client about collecting a midstream urine sample. Which of the following client statements indicate an understanding of the procedure?
"I'll use the cleansing wipe from front to back."
The nurses teaching a new group assistant personnel (AP) about the importance of hand hygiene. Which of the following statement should the nurse include?
"Rub all surfaces of your hands with an alcohol rub for 20 to 30 seconds."
A nurse is teaching an older adult client who has left side at weakness about can use. Which of the following instruction should the nurse include?
"When walking, move your left foot forward first."
A nurse any emergency department is preparing to administer naloxone 0.4mg IV bolus to a client who has opioid-induced respiratory depression. Available is naloxone injection 0.2 mg/mL. How many mL should the nurse administer per dose?
2
A nurse is preparing to infuse a 250 mL unit of packed RBCs over 2hrs. The drop factor of the manual IV tubing is 15gtts/mL. The nurse should adjust the flow rate to deliver how many drops per minute?
31
A nurse is caring for a client requires cold applications with an ice pack to reduce the swelling and pain of an ankle injury. Which of the following action should the nurse take?
Apply the bag for 30 mins at a time
A nurse is teaching a client who has strained her back muscles while preparing to move to a new apartment. Which of the following instruction should the nurse include?
Bend at the knees when picking up an object
A nurse is caring for a client who has a prescription for stool test for guaiac. The nurse understands the purpose of the test is to check the stool for which of the following substances?
Blood
When reviewing the admitting prescriptions for a client, the nurse notes that the dose of one medication is three times the usual dose of this medication. Which of the following action should the nurse take?
Contact the provider to question the dosage
A nurse's planning care for a client who has decreased level of consciousness. The client is receiving continuous enteral feedings via a gastrostomy tube due to an inability to swallow. Which of the following is the priority action by the nurse?
Elevate the head of the client's bed 30° to 45°
A nurse is teaching a newly hired group of assistant personnel (APs) about infectious control measures on the unit. It is crucial for the nurse to remind the aAPs that which of the following is the most effective way to prevent the spread of pathogens during client care?
Performing hand hygiene frequently and consistently
A nurse's discussing indications for urinary catheterization with a newly licensed nurse. Which of the following indications should the nurse include?
Relief of urinary retention Measurement of residual urine after urination An open perineal wound
A nurse is preparing a client for an outpatient surgery. After the nurse and search the IV catheter, the client reports pain the insertion area. Which of the following action should the nurse take?
Remove the catheter and insert another into a different site
A newly licensed nurse is applying prescribed wrist restraints on a client. Which of the following actions should the nurse take?
Secure the restraints using a quick-release tie
A nurse is a meeting a client who has hepatitis C. Which of the following precautions should the nurse implement?
Standard
A nurse is performing tracheostomy care for a client and suctioning to remove copious secretions. Which of the following actions should the nurse take?
Suction two to three times with a 60-second pause between passes
A nurse in a long term care facility is caring for an older dog client who has dementia and begins to have frequent episodes of urinary incontinence. After the provider determines no medical cause for those patients incontinents, Which of the following interventions should the nurse initiate to manage this behavior?
Take the client to the bathroom every 2 hrs
A nurse is preparing to transfer a client who has left sided weakness from the bed to a chair. Which of the following actions should the nurse plan to take?
Use a gait belt to stand and pivot the client
A nurse is planning to perform a sterile dressing thing for a client. Which of the following actions should the nurse plan to take?
Use sterile forceps to move the sterile items on the sterile field
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 massaging the site gently
A nurse is preparing to suction a client who has a tracheostomy. Identify the sequence of actions the nurse should take.
adjust the suction don sterile gloves check the function of the suction catheter hyperoxygenate the patient insert the catheter without suction apply suction while rotating the catheter assess for secretion clearance
And nurses caring for a client who has had an allogeneic hematopoietic stem-cell transplant. Which of the following infection control precautions should the nurse use while caring for the client?
protective
A nurses providing discharge teaching to a client who was recently diagnosed with a latex allergy. Which of the following client statements indicates an understanding of the teaching?
"I will use ink pens for writing."
A nurse enters an older adult client's room to insert a sailing lock. The client asks the nurse, "Why do I need that? I am drinking plenty of fluids." Which of the following responses should the nurse provide?
"Your provider has prescribed antibiotic therapy to be administered intravenously every 6 hours."
A nurse is documenting the intake for a client who is scheduled for an abdominal computed axial tomography (CT) scan. prior to the scan, the client consumes 12 oz sodium diatrizoate and meglumine diatrizoate. The client has an IV of D5 1/2 NS running at 75 ml/hr from 0700 until 1200. The IV runs at 30ml/hr from 1200 to 1500, the client has 6 oz juice. How many mL should the nurse document as the client's intake for the shift?
1,005 mL
A nurse is providing nail care for client. Which of the following action should the nurse take?
Clean under the nail with an orange stick
A nurse is a ministering a cold therapy application to a patient. Which of the following manifestation should the nurse identify as an indication of discontinuing the application due to a systematic response?
Shivering
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 of the client needs further teaching?
"I have a set of my brother's crutches in my basement I can also use."
A nurse is administering an oral medication to an older adult client. The client states, "The pill I always take is green. I don't take an orange pill." Which of the following responses should the nurse make?
"I will check your medication order again."
A nurse's is reinforcing teaching with a client about using transdermal patches at home. Which of the following statements should the nurse identify as an indication that the client understands the teaching?
"I will clean and dry the area before applying the patch."
A nurse is providing home safety information for an older adult client who uses a cane. Which of the following statements should the nurse include in the teaching?
"You should advance your weak leg forward to the cane, then move your strong leg."
a nurse is preparing to administer 0.9% sodium chloride 1,000 mL IV to infuse over 8 hr. The nurse should set the IV pump to deliver how many mL/hr?
125
A nurse is calculating the intake of a client during the past 9 hrs. The clients and take includes lactated Ringer's IV at 150 mL/he, cefazolin 2g IV intermittent bolus in 100 mL of 0.9% sodium chloride, two units of packed RBCs of 275 mL and 250 mL; two IV bolus infusions of 250 mL of 0.9% sodium chloride, ranitidine 50 mg IV intermittent bolus in 50 mL of dextrose 5% in water. How many mL of intake should the nurse record?
2525
A nurse to teach which of the following clients requiring crutches about how to use a three-point gait?
A client who has a right femur fracture with no weight bearing on the affected leg
A nurses were paying a client for ambulation. Which of the following actions should the nurse take to determine the client's level of strength?
Ask the client to push her feet against the nurse's palms
A client receives a wrong medication. The nurse who made the medication error should take which of the following actions first?
Asses the client
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 she should document as which of the following disorders?
Bruxism
A nice is providing hygiene care for a client who is immobile. Which of the following actions show the nurse take? (Select all that apply)
Check for personal items when changing the bed linens Keep the bath water temperature between 43.3°C (110°F) and 46.1°C (115°F) Shave the client's hair in the direction of the hair growth
The nurses were paying a client's evening dose of risperidone when the tablet falls on the countertop. Which of the following actions should the nurse take?
Discard the tablet and obtain another does of medication
A nurse is caring for a group of clients on a medical-surgical unit. Which of the following situations requires that the nurse wear gloves? (Select all that apply.)
Emptying urine from an indwelling urine collection bag providing oral care changing an ostomy pouch
A nurse is teaching a client who has left hemiparesis how to use a cane. which of the following instructions should the nurse include?
Hold the cane on the right side to provide support for the weaker leg
The nurse is preparing to a minister a cleansing enema to a client. Which of the following actions should the nurse take?
Hold the container of solution 30 cm (12 in) above the anus.
A nurse is preparing to administer a 10 units of regular insulin and 20 units of NPH insulin to a client who has diabetes mellitus. When mixing the 2 types of insulin, Which of the following actions should the nurse take first?
Inject 20 units of air into the NPH insulin vial
A nurse is inserting an IV catheter for an older client in preparation for an outpatient procedure. Which of the following veins should the nurse select?
Median vein in the forearm
A nurse is preparing to measure a client's level oxygen saturation and observes edema of both hands and thickened toenails. The nurse should apply the pulse oximeter probe to which of the following locations?
earlobe
