Nursing Fundamentals MidTerm
Clients demonstrating apnea have what?
A temporary cessation of breathing
Upon assessment, the nurse determines the client has a body mass index (BMI) of 45. This finding indicates the client is:
Extremely Obese
A client suffers from chronic pain. The nurse suggests the client have monthly massages. This is an example of:
Palliative Medicine
Which is the best definition of ethics?
The formal, systematic study of moral beliefs
A nurse is providing care for clients in a long-term care facility. What should be the central focus of this care?
The client receiving the care
To practice ethically, the nurse should avoid:
allowing the nurse's own judgment to guide practice
When reviewing the client's history, the nurse notes that the client's last documented bowel movement was 2 days ago. Before the nurse identifies a diagnosis of "Constipation," what assessment must the nurse make?
the nurse should determine the client's normal bowel elimination pattern
The nurse just completed a refresher course on parenteral drug administration. Which statement by the nurse indicates that teaching was effective?
"Reconstitution is the process of adding liquid, known as diluent, to a powdered substance."
The nurse is teaching a client about healing of a minor surgical wound by first intention. What teaching will the nurse include?
"Very little scar tissue will form."
A client who uses portable home oxygen states, "I still like to smoke cigarettes every now and then." What is the appropriate nursing response?
"You should never smoke when oxygen is in use."
Which are the names of the transmission-based precautions defined by the Centers for Disease Control and Prevention (CDC)?
* Airborne precautions * Droplet precautions * Contact precautions
A client reports periodic difficulty falling asleep. Which teaching will the nurse provide? Select all that apply.
* Go on a daily walk * Adhere to a regular schedule for waking and going to sleep * Decrease caffeine intake
Which are considered vital signs?
* Temperature * Pulse * Respiratory Rate * Blood Pressure
A nurse obtaining the most important information first during an assessment of a client is primarily an example of the nurse being:
Able to prioritize
"Acute pain related to instillation of peritoneal dialysate as evidenced by client wincing and grimacing during procedure, client description of experience as "stabbing" is an example of which type of nursing diagnosis?
Actual nursing diagnosis
While assessing a client, the client tells the nurse that he is a follower of traditional Chinese medicine and the concept of qi. Based on the nurse's understanding of this concept, which treatment modality would the nurse expect the client to mention?
Acupuncture
At what period of life do nutrient needs stabilize?
Adulthood
Which word is best described as protection and support of another's rights?
Advocacy
A client is preparing to give a clean-catch specimen. Which instruction will the nurse provide?
After the initial stream is initiated, collect the sample
The nurse is providing perineal care for clients in a hospital setting. What is an appropriate nursing action when providing this type of care?
Always proceed from the most contaminated area to the least contaminated area.
Which organization has established standards that help the nurse determine which clinical actions fall under the scope of nursing practice?
American Nurses Association
The client is scheduled for a polysomnography to determine if the client has obstructive sleep apnea (OSA). The nurse instructs the client to:
Anticipate sleeping overnight at a health care center
The nurse is caring for a client admitted with tuberculosis (TB). What would be the best action by the nurse?
Apply a nonparticulate (N-95) respirator when entering the room
The nurse is preparing to do a focused assessment of the abdomen on a client following an abdominal hysterectomy. Which intervention is most important for the nurse to do prior to the physical assessment?
Ask the client to empty her bladder
During examination a client becomes very tired but still needs to answer questions so that the nurse has sufficient data for planning care. Which action by the nurse would be most appropriate in this situation?
Ask the client whether it is okay to interview the client's spouse for the answers to the interview questions
A client is receiving home care due to an unstable blood pressure. Which nursing intervention is a priority?
Assess the client's blood pressure
A nurse is teaching a young female client about breast cancer prevention. The client asks at what age she needs to begin having mammograms. What is the nurse's best response?
"According to the American and Canadian Cancer Societies, your first mammogram should be done at age 40 and then yearly after that."
An older adult client admitted 4 days ago is being treated for chronic obstructive pulmonary disease (COPD) and now appears confused. What question will the nurse ask to determine the clients level of orientation?
"Can you tell me where you are right now?"
The nurse is caring for a client with an ankle sprain. Which client statement regarding an ice pack indicates that nursing teaching has been effective?
"I will put a layer of cloth between my skin and the ice pack."
Surgical asepsis is defined as:
Absence of all microorganisms
Which principle does not encompass the basic goals of integrative medicine?
Focus on promoting health and preventing illness, as well as treating disease
What must the nurse do to identify actual or potential health problems?
Gather data from sources
A lead nurse is removing personal protective equipment after dressing the infected wounds of a client. Which is the priority nursing action?
Handwashing before leaving the clients room
The type of stool that will be expelled into the ostomy bag by a client who has undergone surgery for an ileostomy will be:
Liquid Consistency
During a health assessment, the nurse uses deep palpation to assess a client's:
Liver
What nursing function would be most commonly found in an ambulatory care facility?
Providing direct client care
A client recovering after an appendectomy is reporting pain. The nurse administers the ordered pain medication and assists the client to splint the incision. What is the nurse's next step in implementing the plan of care?
Reassess the client to determine the effectiveness of the intervention
A nurse is caring for an adult with a fever. The nurse determines that which site is most ideal for obtaining the client's core body temperature?
Rectum
A nurse is caring for a 55-year-old postoperative client. The client returns to the ICU after surgery intubated and mechanically ventilated with a Salem sump nasogastric tube, a Foley catheter, and a PICC line in place. Based on the nurse's knowledge of the most common hospital-acquired infections, which apparatus is most important to remove first?
Urinary Catheter
What is the term for beliefs held by the individual about what matters?
Values
When assessing an infants axillliary temperature, it will be:
1 degree F (0.5 degree C) lower than an oral temperature
Which type of mobility aid would be most appropriate for a client who has poor balance?
A cane with four prongs on the end (quad cane)
A nurse is assessing clients for basal metabolic rate (BMR). Which client would the nurse suspect would have an increased BMR?
A client who has a fever
Which practice is a correct application of infection control practices?
A nurse performs hand washing each time the nurse removes a pair of gloves
A client has been in the hospital for the past 10 days following the development of an infection at her surgical incision site. Each morning, the client reports overwhelming fatigue and has told the nurse, "I just can't manage to get any sleep around here." How should the nurse first respond to this client's statement?
Assess the factors that the client believes contribute to the problem
A nurse attempts to count the respiratory rate of a client via inspection and finds that the client is breathing at such a shallow rate that it cannot be counted. What is an alternative method of determining the respiratory rate for this client?
Auscultating lung sounds, count respirations for 30 seconds, and multiply by 2
A nurse assesses a client for blood pressure. Which technique would be used for this assessment?
Auscultation
A 17-year-old is brought to the emergency department with a head injury. The nurse knows that adolescents are vulnerable to injuries related to:
Automobile accidents
A client diagnosed with cancer has met with the oncologist and is now weighing whether to undergo chemotherapy or radiation for treatment. This client is demonstrating which ethical principle in making this decision?
Autonomy
A nurse is preparing to help a client with a skin infection have a tub bath. In which way can the nurse ensure the client's safety?
Check that the bathroom has a nonskid floor
A nurse administers an antihypertensive medication according to the standardized plan of care for a client with uncontrolled hypertension. Which assessment information indicates the expected client outcome has been met within the first 24 hours?
Client is normotensive
"The client will verbalize appropriate cast care on discharge" represents which type of outcome?
Cognitive
A newly graduated nurse is unable to determine the significance of data obtained during an assessment. What would be the nurse's most appropriate action?
Consult with a more experienced nurse
Which item would alert the home care nurse to a safety hazard threatening a young child?
Dangling blind cords
What is a benefit of regular exercise over time?
Decreased heart rate
A postoperative client is being transferred from the bed to a gurney and states, "I feel like something has just given away." What should the nurse assess in the client?
Dehiscence of the wound
Which describes the best approach for the development of nursing diagnoses?
Develop nursing diagnoses from clusters of significant data
Which is the nurse's priority question to consider prior to delegating a task to an unlicensed assistive personnel (UAP)?
Does this task fall within the scope of a UAP?
The growth in home health care is largely attributed to which factor?
Early discharge of clients from the hospital setting
The nurse is performing an extensive dressing change on a client with burns. The nurse explains each step as it is being performed. The nurse is acting in which role by providing explanation of each step?
Educator
The client is in a rehabilitation unit after a traumatic brain injury. In order to facilitate the clients recovery, what would be the nurse's most appropriate intervention?
Encourage the client to provide as much self-care as possible
The nurse working with the hospital's infection control team is attempting to decrease the transmission of healthcare-associated pathogens. Which intervention will be the most effective?
Encouraging health care workers to utilize hand hygiene
Which of the following is considered to the be the most potent neuromodulators?
Endorphins
The mind and body are connected in the provision of care. This statement describes:
Homeopathic care
A nurse notes that a client admitted to a long-term care facility sleeps for an abnormally long time. After researching sleep disorders, the nurse learns that which area of the client's brain may have suffered damage?
Hypothalamus
The nurse assesses a client and detects the following findings: difficulty breathing, increased respiratory and pulse rates, and pale skin with regions of cyanosis. What condition would the nurse suspect as causing these respiratory alterations?
Hypoxia
A client reports feeling "different" than earlier in the day. When would the nurse anticipate assessing vital signs?
Immediately
When assessing a wound that a client sustained as a result of surgery, the nurse notes well-approximated edges and no signs of infection. How will the nurse document this assessment finding?
Incision
A nurse is assessing a client's pain. The nurse notes which database finding that is indicative of acute pain?
Increased blood pressure
A nurse is using a standardized plan of care for a client. Which action would be most important for the nurse to do?
Individualize the plan to the client
The nurse is preparing to administer a tuberculin test. Which route will the nurse select to administer this injection?
Intradermal
A nurse is using the Z-track technique to administer an injection to a client. Which injection route utilizes the Z-track technique?
Intramuscular
The nurse is attempting to insert a urinary catheter into a female client's bladder and realizes the catheter has been inserted into the vagina. Which action is most appropriate?
Leave the catheter in place as a marker and attempt to insert a new sterile catheter directly above the misplaced catheter
The nurse is caring for a client who is diagnosed with Impaired gas exchange. While performing a physical assessment of the client, which data is the nurse likely to find, keeping in mind the client's diagnosis?
Low pulse rate
A nurse wishes to pursue a degree as a nurse practitioner. What is the minimal degree needed by the nurse?
Master's
A nurse is caring for a client who was administered opioid narcotics. The client reports constipation. What is another potential side effect of opioid narcotics?
Sedation
If the dosage is inappropriate for a client, who is responsible?
Nurse
What is true of nursing responsibilities with regard to a physician-initiated intervention (physician's order)?
Nurses do carry out interventions in response to a physician's order
The nurse is assigned a client who had an uneventful colon resection 2 days ago and requires a dressing change. To which nursing team member should the nurse avoid delegating the dressing change?
Nursing Assistant
A client at a health care facility is being treated for cancer of the bladder. The physician uses a urinary diversion to help the client with urinary elimination. What describes a urinary diversion?
One or both of the ureters are surgically implanted elsewhere
A client returns to the telemetry unit after an operative procedure. Which diagnostic test will the nurse perform to monitor the effectiveness of the oxygen therapy ordered for the client?
Peak expiratory flow rate
A client in a long-term care facility has become increasingly unsteady. The nurses are worried that the client will climb out of bed and fall. Which measure would be a priority recommendation for this client?
Placing the client in a bed with a bed alarm
A nurse is preparing to turn a client who is unable to mobilize independently. Which action best ensures the safety of both the client and the nurse?
Positioning a friction-reducing sheet under the client to facilitate movement
A client describes pain in the lower leg and has been diagnosed with a herniated lumbar disk. The pain in the leg is what type of pain?
Referred pain
The nurse schedules a pulmonary function test to measure the amount of air left in a client's lungs at maximal expiration. What test does the nurse order?
Residual Volume (RV)
The nurse is caring for an older adult client who has refused a bath for several days and has now developed a rash on the buttocks. What is the priority nursing intervention?
Schedule a bath in the morning or evening according to client's preferred bathing time
A client's pressure injury is superficial and presents clinically as an abrasion, blister, or shallow crater. How would the nurse document the pressure injury?
Stage II
"The levels of performance accepted by and expected of nursing staff or other health team member" defines:
Standards
The nurse has been educating the client about how to use a walker safely. The nurse knows that the education has been effective when the client:
Steps into the walker when walking
A 70-year-old client who has four children and six grandchildren states that she "wets" herself when she sneezes or laughs. She reports that sometimes this also occurs when rising from a sitting to standing position. Which type of incontinence does the nurse anticipate?
Stress
While auscultating a client's lung sounds, the nurse notes crackles in the left lower lobe, which were not present at the start of the shift. The nurse is engaged in which type of nursing intervention?
Surveillance
The nurse is inserting a urinary catheter into a 63-year-old male client and encounters resistance. What is the most likely cause of the resistance?
The client has an enlarged prostate
Which statement is true when comparing home care with acute care?
The nurse is the guest in the client's home
A nurse is completing an intake assessment. The nurse notes that an older adult male client appears to have bruises in varying stages of healing. Which action by the nurse indicates an understanding of her responsibilities?
The nurse should question the client about the sources of the bruises.
Which action would cause a charge nurse to have concerns about a nurse's moral agency?
The nurse was seen at a grocery store after calling in sick
A registered nurse wishes to work as a nurse researcher. Which is true regarding nurse researchers?
They are responsible for the continued development and advancement of nursing
The nurse is preparing to delegate a bath for a 90-year old client who is non-responsive and has mild skin breakdown. Which type of bath will the nurse delegate to the unlicensed assistive personnel?
Traditional bed bath with linen change
A nurse is educating a group of adolescent girls on bone and teeth growth. Which fat-soluble vitamin assists to build bone and teeth?
Vitamin D
A nurse is providing perineal care for a female client who has a decreased level of consciousness. Which technique should the nurse employ when providing this care?
Wipe from the pubic area toward the anal area
The need for university-based nursing education programs was brought to light during which important historical time?
World War II
