Learning System RN 3.0 Fundamentals Practice

A nurse is preparing to insert an NG tube for a client who has a bowel obstruction. Which of the following actions should the nurse take first?

Explain the procedure to the patient

A nurse is caring for a middle-aged adult client.. The nurse should identify which of the following statements as an indication that the client has completed Erikson's developmental task for her age group?

" I think I have done a good job with my children since they are all independent now"

A nurse is caring for a client who is receiving mechanical ventilation via a tracheostomy tube and has a gastrostomy tube for enteral feedings. Which pieces of info are critical to communicate to the next nurse who will be caring for this client?

- new prescriptions - ABG results - tracheal secretion characteristics

A nurse in a providers clinic is taking a client's age, height, weight, and vital signs. The nurse should identify this action as part of which of the following components of the nursing process?

Assessment

A nurse is caring for a client who was transferred to the surgical unit by stretcher from the PACU. Which of the following actions should the nurse perform immediately following the transfer?

Check the client's vital signs

A nurse is preparing to administer oral phenytoin to a client who has a seizure disorder. Before administering the medication, which of the following actions should the nurse take?

Check the medication dose and the client's identification

A nurse is caring for a client who has a stage II pressure ulcer. Which of the following wound dressings should the nurse apply to the ulcer?

Hydrocolloid dressing

A nurse is assessing a client's peripheral pulses. Which of the following descriptions should the nurse use to document the findings?

Peripheral pulses bilaterally symmetric, equal, and strong in all 4 extremeties

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 client threw the medication on the floor.

A nurse is providing nutrition counseling to a middle-aged adult client who has a secondary job. Which of the following factors should the nurse consider?

The client's basal metabolic rate could decrease

A nurse is caring for a client who was admitted to a LTC facility for rehab after a total hip arthroplasty. At which of the following times should the nurse begin discharge planning?

Upon the client's admission to the care facility

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 HR to take longer to return to normal after exercise as I get older."

A nurse is caring for a client who is scheduled to receive transcutaneous electrical nerve stimulation (TENS) for pain management. The client asks the nurse how a TENS unit helps relieve pain. Which of the following responses should the nurse make?

"It modulates the transmission of the pain impulse."

While in the hospital, a client who has a terminal illness tells the nurse, "I can't believe I'm dying. A lot of bad people in the world are healthy, and here I am dying!" Which of the following responses should the nurse provide?

"Tell me more about how you feel about dying."

A nurse is providing discharge teaching for a client who has type 2 diabetes mellitus and will be caring for herself at home. The client expresses concerns about preparing an appropriate diet for her diabetes due to her cultural beliefs and preferences. Which of the following responses should the nurse offer?

"The dietician will help you give a list of foods and dietary choices to keep your diabetes under control."

A nurse is preparing to administer sotalol to a client with a prescription for 320 mg/day divided equally every 12 hours. The medication is available in 80 mg tablets. How many tablets should the nurse administer per dose?

2 tablets

A nurse is calculating a client's intake for a 12 hr shift. The client had dextrose 5% in 0.45% sodium chloride infusing at 125 mL/hr, gentamicin 150 mg in 100 mL at 1400, famotidine 20 mg in 50 mL at 1000 and 1600, 250 mL of blood over 2 hr, and a nasogastric flush of 30 mL every 2 hours. What is the total intake in milliliters that the nurse should document for this client for this 12-hr period?

2130

A nurse is preparing to administer 40 mL of 0.9% sodium chloride IV to infuse over 20 minutes. The drop factor of the manual IV tubing is 15 gtt/mL. the nurse should set the manual IV infusion to deliver how many gtt/min?

30

A nurse is caring for a client who has emphysema. The client has not stopped smoking cigarettes and states, "It's too late for me to quit." Which of the following actions should the nurse take?

Assist the client in finding local smoking-cessation assistance programs

A nurse is receiving a client from the PACU who post-op is following abdominal surgery. Which of the following actions should the nurse perform to transfer the client from the stretcher to the bed?

Lock the wheels on the bed and the stretcher

A nurse is preparing to insert an indwelling urinary catheter for a female client. Which of the following actions should the nurse have the client perform just before inserting the catheter?

Bear down gently

A nurse in a provider's office is assessing a client who has heart failure. The client has gained weight since her last visit, and her ankles are edematous. Which of the following findings is another clinical manifestation of fluid volume excess?

Bounding pulse

A nurse is caring for a client who is 48 hours post-op following a small bowel resection. The client reports gas pains in the periumbilical area. The nurse should plan care based on which of the following factors contributing to this post-op complication?

Impaired peristalsis of the intestines

A nurse is reviewing the laboratory values of a client who has a plosive Chvostek's sign. Which of the following laboratory findings should the nurse expect?

Decreased Calcium Calcium is necessary for nerve conduction and muscle contractions. When the client is hypocalcemia, tetany and muscle spasms may occur.

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

A nurse is communicating with a group of clients about what to expect during the post-op phase of a total hip arthroplasty. Which of the following elements of the communication process should the nurse identify as an evaluation of effective communication?

Feedback is provided

A nurse is preparing to administer a partial dose of a prefilled opioid analgesic 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

A nurse is caring for a client who is receiving continuous enteral feedings through an NG tube and develops diarrhea. Which of the following actions should the nurse take?

Request a prescription for an isotonic enteral nutrition formula

A community health nurse is preparing a campaign about seasonal influenza. Which of the following plans should the nurse include as a form of secondary prevention?

Screening groups of older adults in nursing care facilities for early influenza manifestations.

A nurse is assessing a client's respiratory system. Which of the following breath sounds should the nurse expect to hear over the periphery of the major lung fields?

Vesicular