PN Fundamentals Online Practice 2020 A
A nurse is contributing to the plan of care for a client who has a prescription for elastic bandages to the lower extremities. Which of the following actions should the nurse recommend for the plan of care? Check for capillary refill proximally to the elastic bandages every 12 hr Compare the client's pedal pulses bilaterally every 4 hr. Place the clients legs in a dependent position for 30 min before applying the elastic bandages Remove the elastic bandages every other day to inspect the skin
Compare the client's pedal pulses bilaterally every 4 hr. The nurse should compare the pedal pulses bilaterally every 4 hr to check for adequate circulation for a client who has elastic bandages on their lower extremities.
A nurse is preparing to administer a topical medication to a client. Which of the following actions should the nurse take?
Compare the label of the medication container with the medication administration record three times.
A nurse is reviewing the medical record of a client who has heart failure. The nurse should identify which of the following laboratory results as an indication that the client has fluid volume excess? Urine specific gravity 1.015 Hematocrit 42% Urine pH 6.5 BUN 8 mg/dL
BUN 8mg/dl A BUN of 8 mg/dL is below the expected reference range of 10 to 20 mg/dL. With fluid volume excess, the nurse should expect the client's BUN to be below the expected reference range due to hemodilution.
A nurse is assisting with the admission of a client who has brought their medications to the facility. Which of the following actions should the nurse take?
Compare the medications the provider has prescribed with the client's medications from home.
A nurse is speaking with a client who has type 2 diabetes mellitus and a prescription for insulin. The client verbalizes anger about having to take insulin. Which of the following responses should the nurse make? "Why are you angry about taking insulin?" "Don't worry. Diabetes runs in my family as well." "I see that you are angry. Let's sit down and talk." "You should take insulin, because it reduces the risk for complications."
"I see that you are angry. Let's sit down and talk." This is an example of the therapeutic communication technique of offering self. It provides an opportunity for the nurse to understand the reason for the client's anger and provides a means for further communication.
A nurse is reinforcing teaching about the use of crutches with a client who has a fractured right tibia and fibula. Which of the following statements by the client indicates an understanding of the teaching?
"I will be sure to keep the crutch tips dry."
A nurse is caring for a client who has metastatic cancer and practices Catholicism. The client asks the nurse to discuss the afterlife with them. Which of the following statements by the nurse assists in meeting the client's spiritual needs? "Tell me what the afterlife means to you." "You should discuss the afterlife with your priest." "Keep praying. A miracle could happen" "Maybe your condition will lead you closer to God"
"Tell me what the afterlife means to you." This statement respects the client's spiritual needs by using open-ended therapeutic communication to assist the client to talk about their concerns.
A nurse is reinforcing teaching with a client about living wills. Which of the following client statements indicates an understanding of the teaching? "The living will directs my medical care when I am unable to make decisions." "I should have a nurse cosign my living will." "After signing the living will, I will not be able to make any changes." "I am required by Medicare to have a living will when I am admitted to the hospital."
"The living will directs my medical care when I am unable to make decisions." The living will provides specific directions for a client's medical treatment when the client is unable to make decisions due to their health status.
A nurse is caring for a client who has a terminal illness and a family member asks why the client's mouth is continually open. Which of the following responses should the nurse make? "The reduced muscle tone has relaxed the jaw muscles." "That happens when a person gets close to death" "I can apply a chin strap to help hold the mouth closed" "You shouldnt worry about that at this time"
"The reduced muscle tone has relaxed the jaw muscles." Prior to death, decreased muscle tone causes jaw muscles to relax, resulting in an open mouth.
A nurse is reinforcing preoperative teaching with a client about how to turn, cough, and deep breathe. Which of the following statements by the client indicates an understanding of the teaching?
"This can help prevent pneumonia."
A nurse is reinforcing teaching about hospice care measures with the family of a client who is dying. Which of the following statements by a member of the client's family indicates an understanding of the teaching?
"We will keep her room cool to help her breathe better."
A nurse is caring for a client who has recently undergone a total bilateral mastectomy. Which of the following statements by the client requires immediate action by the nurse?
"When I look at myself in the mirror, I don't know if I can go on."
A nurse is reinforcing teaching with a client about the prevention of stress injuries. Which of the following instructions should the nurse include? "Keep your knees in a locked position when standing for prolonged periods" "Bend at the waist when lifting a heavy object" "Keep your feet close together when lifting a heavy object" ""When lifting a heavy object, keep it close to your body."
"When lifting a heavy object, keep it close to your body." The nurse should instruct the client to keep the object as close to their body as possible to increase stability and decrease back strain when lifting a heavy object.
A nurse is reinforcing dietary teaching with a client who has chronic kidney disease and requires a low-potassium diet. Which of the following food choices by the client demonstrates an understanding of the teaching?
1 cup of applesauce
A nurse is calculating the intake and output for a client over the last 8 hr. The client is receiving a continuous IV infusion at 150 mL/hr and had 4 oz of juice and 0.5 L of water. How many mL of fluid should the nurse document as the client's intake for the last 8 hr? (Round your answer to the nearest whole number.)
1820 mL
A nurse is reviewing the vital signs of four adult clients. Which of the following findings requires further data collection by the nurse? A client who has a respiratory rate of 12/min A client who has a blood pressure of 110/74 mm Hg A client who has a temperature of 37.3° C (99.2° F) A client who has a pulse rate of 110/min
A client who has a pulse rate of 110/min This client's heart rate is above the expected reference range of 60 to 100/min. Therefore, the nurse should collect further data to determine the cause of the tachycardia.
A nurse is providing wound care for a group of clients. Which of the following wounds should the nurse identify as healing by secondary intention? A stage 3 pressure injury on the coccyx A contaminated wound that is closed after 72 hr A puncture wound that is sutured An abdominal surgical wound with intact staples
A stage 3 pressure injury on the coccyx The nurse should identify a pressure injury and other wounds with edges that are not approximated as healing by secondary intention.
A nurse is assisting with the plan of care for a client who has a bacterial infection and a persistent oral temperature of 38.9° C (102° F). Which of the following interventions should the nurse include in the plan of care to treat the fever? Administer acetaminophen. Apply ice packs to the client's axillae. Maintain the room temperature at 18.3° C (64.9° F). Assist the client to ambulate four times a day.
Administer acetaminophen The nurse should administer acetaminophen or an NSAID such as ibuprofen to the client to reduce the body's temperature. Acetaminophen inhibits the synthesis of prostaglandins, resulting in a reduced fever.
A nurse is planning to perform wound irrigation for a client who has a large abdominal wound. Which of the following actions should the nurse plan to take? Administer an analgesic 30 min before starting the procedure. Hold the syringe 5 cm (2 in) above the upper end of the wound. Place the irrigation solution in a basin of cool water. Perform the wound irrigation with a 10-mL syringe with an angiocatheter.
Administer an analgesic 30 min before starting the procedure. The nurse should administer an analgesic to promote pain control, which allows the client to move more easily and be positioned to facilitate the irrigation procedure.
A nurse is caring for four clients who are required to provide informed consent for treatment. The nurse should identify that which of the following clients is able to provide informed consent? A client who is receiving opioid medications via a PCA pump A client who has moderate Alzheimer's disease An 18-year-old client who has acute appendicitis A 16-year-old client who has a fractured tibia
An 18-year-old client who has acute appendicitis A competent 18-year-old client who has acute appendicitis is able to provide informed consent for treatment.
A nurse is caring for a postoperative client who is at risk for thrombus formation. Which of the following interventions should the nurse delegate to an assistive personnel (AP)? Apply thromboembolic stockings. Monitor the circulation in all four extremities Record the condition of the clients skin Reinforce teaching about performing range of motion exercises
Apply thromboembolic stockings. The application of thromboembolic stockings is within the range of function of an AP and does not require further data collection by the nurse.
A nurse is assisting with the plan of care for a client who has aphasia following a stroke. Which of the following interventions should the nurse use to assist the client with communication?
Ask the client close-ended questions.
A nurse is caring for a client who is postoperative and is experiencing nausea and vomiting. The nurse should identify which of the following findings as indications that the client has fluid volume deficit? (Select all that apply.) Full bounding pulse Cool extremities Moist crackles in the lungs Orthostatic hypotension Flat neck veins
Cool extremities, can indicate fluid volume deficit. Orthostatic hypotension, indicates fluid volume deficit. Flat neck veins, indicate fluid volume deficit.
A nurse is assisting with the admission of a client who has active tuberculosis. Which of the following actions should the nurse plan to take?
Assign the client to a negative-pressure airflow room.
A nurse is assisting with the plan of care for four clients. Which of the following tasks should the nurse assign to an assistive personnel (AP)?
Assist a client to get out of bed after a breathing treatment.
A nurse is using Maslow's hierarchy of needs in assisting with discharge planning for a client. Which of the following activities should the nurse recommend as the priority for this client? Volunteer at the local food pantry. Attend an exercise program. Find an enjoyable hobby. Support environmental conservation.
Attend an exercise program When using Maslow's hierarchy of needs, the nurse should determine that the priority activity is to fulfill the client's physiological needs for activity. Therefore, the nurse should recommend exercise and help the client select a suitable exercise program.
A nurse is explaining ethics and values to a newly licensed nurse. The nurse should explain that allowing a client to make a decision about a treatment is an example of which of the following ethical principles?
Autonomy
A nurse is preparing to administer an enteral feeding to a client who has an NG tube in place. Which of the following methods should the nurse use to verify correct placement of the NG tube? Check the pH of the gastric aspirate Observe the color of the gastric aspirate after adding blue dye to the formula Auscultate over the epigastrium Measure the length of the inserted NG tube
Check the pH of the gastric aspirate The nurse should check the pH of the gastric contents to verify tube placement. A pH greater than 6 is an indication that the nurse has aspirated respiratory contents or that the tube is in the intestine, and that the nurse should withhold the feeding.
A nurse is assisting with a presentation to a group of older adults at a community center about hypothermia and hyperthermia. Which of the following information should the nurse include about age-related changes?
Circulation becomes less efficient with age.
A nurse is preparing to remove a client's peripheral IV catheter. After performing hand hygiene and applying clean gloves, which of the following actions should the nurse take first? Clamp the infusion tubing. Remove the dressing. Withdraw the catheter from the vein. Ensure the catheter is intact.
Clamp the infusion tubing. Evidence-based practice indicates that the nurse should first clamp the infusion tubing after applying clean gloves. This action stops the flow of the IV fluid and prevents it from leaking out during the IV removal.
A nurse is assisting with the care of a recently deceased client. Which of the following actions should the nurse complete prior to the family viewing the body? Remove dentures Apply a shroud around the body with a visible id tag Clean soiled areas of the body Place the clients head in a dependent position
Clean soiled areas of the body. A complete bath is not necessary because the body will be washed by the mortician. The nurse should cleanse any soiled areas prior to the family viewing the body, make sure dentures are in place if applicable, and comb the client's hair.
A nurse is caring for a client who is receiving continuous NG tube feedings. The nurse listens to the client's bowel sounds. Which of the following actions should the nurse take? Replace the NG tube place Place the client in the sims position Decrease the rate of feeding Check the clients blood glucose
Decrease the rate of the feeding The nurse should expect to hear bowel sounds every 5 to 35 seconds. This audio clip indicates hypermotility because there are greater than 40 bowel sounds/min. Hypermotility leads to diarrhea and is an indication of intolerance to the enteral feeding. Therefore, the nurse should slow the rate of the feeding to promote the client's tolerance of the feeding.
A nurse is caring for a client who is refusing medical treatment. Which of the following actions should the nurse take?
Document the client's refusal of the treatment.
A nurse has delegated various client care tasks to the assistive personnel (AP) on the care team. Which of the following actions by the AP should the nurse identify as correct?
Donning a mask to measure the vital signs of a client who has pertussis
A nurse is preparing to palpate a client's pulse. The nurse should recognize that which of the following pulses is located on the top of the client's foot? Posterior tibial Dorsalis pedis Popliteal Brachial
Dorsalis pedis The nurse should document palpating the dorsalis pedis pulse on the top of the foot. According to evidence-based practice, the nurse should identify that precontemplation is the first stage the client will experience when using the stages of health behavior change. In this stage, the client avoids discussing the behavior and does not intend to make a change in behavior. The stages of health behavior change are precontemplation, contemplation, preparation, action and the maintenance stage.
A nurse is caring for a client who has an indwelling urinary catheter. Which of the following actions should the nurse take to prevent urinary tract infections? Empty the urine drainage bag every 12 hr. Drain urine from the tubing before ambulation. Use clean technique for urine specimen collection. Hang the urine drainage bag at the level of the bladder.
Drain urine from the tubing before ambulation Draining urine from the tubing before ambulation will prevent backflow of urine into the bladder.
A nurse is planning care for a client who is disoriented and at risk for falls. Which of the following interventions should the nurse include? (Select all that apply.) Ensure that the client is wearing nonskid slippers Move the bedside table away from the bedside . Place the client in a room near the nurses' station Keep the bed's full side rails in the up position Reinforce teaching about how to use the call bell
Ensure that the client is wearing nonskid slippers. Nonskid slippers provide better traction and can help prevent slipping and falling. Place the client in a room near the nurses' station. Keeping the client close to the nurses' station allows for more frequent observation to help identify actions that increase the risk for falls. Reinforce teaching about how to use the call bell. Even if the client is confused, it is important to reinforce the use of the call bell for assistance to help prevent the client from attempting actions that could increase the risk for falls.
A nurse is contributing to the plan of care for a client who has a positive throat culture for streptococci. Which of the following interventions should the nurse recommend to be included in the plan of care? Place the client in a room with another who has pharyngitis Ensure that the client wears a surgical mask during transportation throughout the facility. Limit the client's visitors to visitations of 30 min Provide the client a room with negative-pressure airflow of six exchanges per hour
Ensure that the client wears a surgical mask during transportation throughout the facility. Streptococcal pharyngitis requires droplet precautions. The nurse should instruct the client to wear a surgical mask when outside of the room to prevent the spread of infection. Staff should make every attempt to limit the client's movement outside of the room.
A charge nurse smells smoke, enters the visitor restroom, and sees flames in the trash can. What is the sequence of actions that the nurse should take? (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.) Evacuate clients from the area is the first step. Pull the lever on the fire alarm box is the second step. Close the fire doors on the unit is the third step. Use a fire extinguisher to put out the fire is the fourth step.
Evacuate clients from the area is the first step. The first action the nurse should take when using the RACE protocol is to "rescue" or evacuate the clients from the area to prevent harm. Pull the lever on the fire alarm box is the second step. For the next step, "alarm," the nurse should activate the facility fire alarm and call to report the fire to the facility emergency extension. Close the fire doors on the unit is the third step. For the third step, "confine," the nurse should close the unit fire doors to prevent the fire from spreading. Use a fire extinguisher to put out the fire is the fourth step. For the final step, "extinguish," the nurse should use a fire extinguisher to put out the fire by aiming the nozzle at the base of the fire and using a sweeping motion.
A nurse is reinforcing teaching with a client who has a partial hearing loss about how to modify the home environment. Which of the following is a priority modification that the nurse should include?
Flashing smoke alarm
A nurse is repositioning a client who has quadriplegia and is in the supine position. Which of the following actions should the nurse take to prevent client musculoskeletal injury?
Internally rotate the client's hips by using a trochanter roll
A client who has advanced cancer tells the nurse that they have a difficult time talking to anyone about the illness. Which of the following actions should the nurse take to encourage therapeutic communication? Keep the conversation moving by asking about the client's family Let the client know that, as their nurse, they are available and willing to listen. Ask if the client understands what to expect in the advanced stages of the illness Ask the clients visitors not to say anything about the advanced disease
Let the client know that, as their nurse, they are available and willing to listen. Active listening conveys the nurse's respect and acceptance for the client's feelings and gives the client an opportunity to express their thoughts and needs.
A nurse is caring for a client who has a Clostridium difficile infection. Which of the following solutions should the nurse use to perform hand hygiene while caring for this client? Isopropyl alcohol Mild soap Chlorhexidine Triclosan
Mild soap The CDC recommends using soap and water for handwashing when caring for clients who have a C. difficile infection. C. difficile is a spore-forming bacterium that is difficult to kill with disinfectants.
A nurse is preparing to administer oxygen to a client who has heart failure and is having severe difficulty breathing. Which of the following oxygen delivery equipment should the nurse select to provide the highest concentration of oxygen to the client? Nasal cannula Simple face mask Venturi mask Nonrebreather mask
Nonrebreather mask A nonrebreather mask provides the highest percentage of oxygen concentration without intubation and mechanical ventilation.
A nurse is contributing to a plan of care for a client who has a new prescription for a wrist restraint. Which of the following actions should the nurse include in the plan? Check that the restraint is tied to a fixed frame of the bed. Pad bony prominences on the wrist. Remove the restraint every 4 hr to allow movement. Tie the restraint with a knot that will tighten when pulled.
Pad bony prominences on the wrist The nurse should pad bony prominences on the wrist to prevent skin breakdown caused by the restraint rubbing against the client's skin.
A nurse is moving a client up in bed with the assistance of a second nurse. Which of the following actions should the nurse take? Stand facing the center of the bed at the client's side. Place feet apart with the foot nearest the head of the client's bed in front of the other foot. Keep knees and hips straight while bending at the waist toward the client. Encourage the client to keep their legs straight and remain still.
Place feet apart with the foot nearest the head of the client's bed in front of the other foot. Placing the feet apart provides a wide base of support, which improves balance. Additionally, a forward-backward stance enables the nurse to shift their weight as the client moves up in bed.
A nurse is collecting data from a client who has an NG tube set to low intermittent suction. Which of the following findings indicates hypomagnesemia?
Positive Chvostek's sign
A nurse is reinforcing teaching with a client about smoking cessation. Which of the following should the nurse identify as the first stage of health behavior change? Precontemplation Preparation Maintenance Action
Precontemplation
A nurse is reinforcing preoperative teaching with a client who speaks a different language than the nurse. Which of the following actions should the nurse take?
Provide handouts written in the client's primary language.
A nurse is preparing to collect data from a client for a health assessment. Which of the following actions should the nurse take? Provide privacy for the client. Keep the lights at a dim level Expose half of the body at a time Encourage the clients friend to remain in the room
Provide privacy for the client. The nurse should promote a therapeutic environment by providing privacy while data is being collected for a health assessment.
A charge nurse is reinforcing teaching with an assistive personnel (AP) about performing pulse oximetry. Which of the following information should the nurse include in the teaching? Select an alternate site to place the oximetry probe if the capillary refill is less than 2 seconds. Use an adhesive oximetry probe for a client who has a latex allergy. Remove polish from the client's fingernail before applying the oximetry probe. Lubricate the tip of the oximetry probe.
Remove polish from the client's fingernail before applying the oximetry probe. The nurse should instruct the AP to remove the client's fingernail polish on at least one finger before placing the probe on that finger because the sensor needs to detect a pulsating vascular bed to produce a reading.
A nurse is preparing to transfer a client from an acute care facility to a long-term care facility. Which of the following information should the nurse plan to include in the transfer report? Discontinued medications Resolved health conditions
Resolved health conditions The nurse should report both unresolved and resolved health conditions to promote continuity of care.
A nurse is taking notes of client information on a piece of paper while receiving report. Which of the following actions should the nurse take to dispose of the paper? Obscure the clients name with a marker prior to disposal Place the paper in a trash can at the nurses station Shred the paper in a secure container Secure the paper in the nurses personal locker
Shred the paper in a secure container. The nurse should shred any written information in a secure container after use to protect the client's privacy and adhere to HIPAA guidelines.
A nurse at a long-term care facility is caring for a client who is alert. Which of the following actions should the nurse take to protect the client's privacy? Place the client's medication record on the bedside table while ambulating the client. Give report about the client's status while standing at the nurses' station. Speak with the client about their condition after visitors have left. Place a message board in the client's room to post dietary information.
Speak with the client about their condition after visitors have left. The nurse should ensure a private environment before discussing the client's condition with them.
A nurse is reinforcing teaching with a client about the use of crutches. Which of the following actions by the client indicates an understanding of the teaching?
The client advances the unaffected leg first while climbing stairs.
A nurse is collecting data from an older adult client. Which of the following findings should the nurse report to the provider? The client has smooth, brown, irregular lesions on the back of each hand. The client has glossy, white circles around the periphery of the corneas. The client reports urinary incontinence. The client reports a decreased sense of taste.
The client reports urinary incontinence. Aging is a risk factor for urinary incontinence as older adult males can experience hypertrophy of the prostate gland, and older adult females can experience stress incontinence with laughing, sneezing, or coughing. Urinary incontinence is an abnormal condition that can impact the quality of life for older adults. Urinary incontinence should be investigated; therefore, the nurse should report this finding to the provider. Interventions can be reinforced to the client to promote improved urinary function.
A nurse is caring for a client who has just died and practiced the Islamic faith. Which of the following cultural practices should the nurse expect? The clients body should be placed on the floor The clients oldest child will bathe the body The client's face should be turned toward Mecca The clients body will be adorned with amulets
The client's face should be turned toward Mecca Following death, it can be a practice of the Islamic faith to turn the face of a deceased person toward Mecca.
A nurse is collecting data on four clients. Which of the following findings should the nurse report to the provider? Heart rate 62/min Urine output of 200 mL over 8 hr Pulse oximetry 95% on room air BP 112/76 mm Hg
Urine output of 200 mL over 8 hr A urinary output of less than 30 mL/hr can indicate low blood volume or kidney malfunction. The nurse should report an output that averages 25 mL/hr to the provider.
A nurse is reinforcing teaching about health promotion with a group of young adult clients. Which of the following information should the nurse include?
Young adults should receive a dental assessment every 6 months.
A nurse is caring for a client who has a prescription for a potassium supplement. The client tells the nurse that the pill is too large to swallow and refuses to take it. The nurse offers to break the pill into two smaller pieces. The nurse is demonstrating which of the following ethical principles?
beneficence
