Quiz 14 Fundies

A nurse is monitoring a client's fluid intake. For breakfast, the client consumed 8 oz of milk, 10 oz of water, 4 oz of flavored gelatin, 1 scrambled egg, 1 crisp piece of bacon, and 2 biscuits with jelly. How many mL should the nurse record as the client's fluid intake? (Fill in the blank with the numeric value only, round the answer to the nearest whole number, and use a leading zero if applicable. Do not use a trailing zero.)

660

A nurse is caring for a client who reports not sleeping at night, which interferes with her ability to function during the day. Which of the following interventions should the nurse suggest to this client? A. Avoid beverages that contain caffeine B. Take a sleep medication regularly at bedtime C. Watch television for 30 min in bed to relax prior to falling asleep D. Advise the client to take several naps during the day

A. Avoid beverages that contain caffeine

A nurse is providing discharge teaching to an older adult client about personal safety. Which of the following statements by the client indicates an understanding of the teaching? A. "I will have the steps to my house painted a dark color." B. "I will put a night-light in the hallway." C. "I will put on socks when I get out of bed." D. "I will secure any wires in my home under rugs."

B. "I will put a night-light in the hallway."

A nurse is administering an IM injection to a 5-month-old infant. Which of the following injection sites should the nurse use? A. Deltoid B. Ventrogluteal C. Vastus lateralis D. Dorsogluteal

C. Vastus lateralis

A nurse is planning to insert a nasogastric tube for a client after explaining the procedure. The client states, "You are not putting that hose down my throat." Which of the following statements should the nurse make? A. "Let's get the process over with because you won't get better without this tube." B. "You should talk to your provider about your fears." C. "Why don't you want the tube inserted?" D. "I can see that this is upsetting you."

D. "I can see that this is upsetting you."

A nurse is caring for a client who has cancer and refuses visitors because of his debilitated physical appearance. Which of the following comments should the nurse make? A. "Yo u look just fine to me." B."Nobody expects you to look beautiful in the hospital." C. "I understand how you feel. I would feel the same way." D. "Would you like to talk about how you feel?"

D. "Would you like to talk about how you feel?"

A nurse is preparing to change a dressing on a client who is receiving negative pressure wound therapy (NPWT). What sequence of actions should the nurse plan to take? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Turn off the vacuum on the NPWT device and administer the prescribed analgesic. Remove the soiled dressing and perform hand hygiene. Apply sterile or clean gloves and irrigate the wound. Apply a skin protectant or a barrier film to the skin around the wound. Place prepared foam into the wound bed and cover with a transparent dressing. Connect the tubing to transparent film and turn on the NPWT unit.

A nurse is teaching a client who has low back pain about heat therapy. Which of the following statements by the client indicates an understanding of the teaching? A. "I need to place a towel between the heating pad and my skin." B. "I'll need to turn up the temperature if I can't feel the heat." C. "I'll sleep on top of the heating pad to increase the heat penetration." D. "Keeping the heat continuously on my back will help it heal."

A. "I need to place a towel between the heating pad and my skin."

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? A. Assist the client in finding local smoking-cessation assistance programs B. Tell the client that she will be all right after receiving medical care C. Inform the client that she must stop smoking or the provider will not be able to care for her D. Advocate for the client by supporting her statement about not quitting

A. Assist the client in finding local smoking-cessation assistance programs

A nurse is preparing to insert an indwelling urinary catheter. Which of the following instructions should the nurse give the client to ease the passage of the catheter through the urinary meatus? A. "Bear down." B. "Perform Kegel exercises." C. "Hold your breath." D. "Raise your head off of the pillow."

A. "Bear down."

A nurse is planning an in-service training session about nutrition. Which of the following statements should the nurse include in the teaching? A. "Fats provide energy." B. "Carbohydrates repair body tissue." C. "Fats regulate fluid balance." D. "Carbohydrates prevent interstitial edema."

A. "Fats provide energy."

A nurse is performing a focused assessment of a client's peripheral vascular system. In which of the following locations should the nurse palpate the posterior tibial pulse? A. Below the medial malleolus B. In the popliteal fossa C. In the antecubital space D. On the dorsum of the foot

A. Below the medial malleolus

A nurse is planning care for a client who is confused and requires a prescription for wrist restraints. Which of the following interventions should the nurse include in the plan of care? A. Renew the prescription for the use of restrains within 24 hr B. Secure the restraint with the buckle side next to the client's skin C. Ensure 4 fingers can be inserted under the secured restraint D. Remove the restraint every 3 hr

A. Renew the prescription for the use of restrains within 24 hr

A nurse is reviewing a client's laboratory report. The client's ABG levels are pH 7.5, PaCO2 32 mmHg, and HCO3- 24 mEq/L. The nurse should determine that the client has which of the following acid-base imbalances? A. Respiratory alkalosis B. Metabolic acidosis C. Respiratory acidosis D. Metabolic alkalosis

A. Respiratory alkalosis

A nurse is assessing a client who is unconscious. Family members are present and answer the nurse's questions about the client's medical history. The nurse should document this information as which of the following types of data? A. Secondary-source data B. Experiential data C. Primary-source data D. Quantitative data

A. Secondary-source data

A nurse is teaching a client who is recovering from gallbladder surgery how to use an incentive spirometer. Which of the following pieces of information should the nurse include in the teaching? A. Exhale slowly to reach the goal volume B. Hold the breath for 5 sec after goal volume is reached C. Continue to breathe deeply between each cycle D. Limit the repeat pattern of breathing to 5 breaths

B. Hold the breath for 5 sec after goal volume is reached

A nurse is caring for a client who reports feeling a pop after coughing without properly splinting an abdominal incision. On assessment, the nurse notes that the client's wound has eviscerated. Which of the following actions should the nurse take? (Select all that apply.) A. Carefully reinsert the intestine through the opening in the wound B. Place the client in a supine position with the hips and knees flexed C. Leave the room to call the surgeon D. Cover the wound and intestine with a sterile, moistened dressing E. Monitor the client for manifestations of shock

B. Place the client in a supine position with the hips and knees flexed D. Cover the wound and intestine with a sterile, moistened dressing E. Monitor the client for manifestations of shock

A nurse is caring for a client who is postoperative and has paralytic ileus. Which of the following abdominal assessments should the nurse expect? A. Frequent bowel sounds with flatus B. Absent bowel sounds with distention C. Hyperactive bowel sounds with diarrhea D. Normal bowel sounds with increased peristalsis

B. Absent bowel sounds with distention

A nurse is caring for a client who has a terminal illness. The client asks several questions about the nurse's religious beliefs related to death and dying. Which of the following actions should the nurse take? A. Change the topic because the client is trying to divert attention from the illness B. Encourage the client to express thoughts about death and dying C. Tell the client that religious beliefs are a personal matter D. Offer to contact the client's minister or the facility's chaplain

B. Encourage the client to express thoughts about death and dying

A nurse is caring for an older adult client who has an in-the-canal hearing aid. The client states that the hearing aid is making a whistling sound. The nurse should identify which of the following factors as the source for this sound? A. low battery power B. Excessive wax in the ear canal C. A volume setting that is too low D. A crack in the ear tube

B. Excessive wax in the ear canal

A nurse is changing the dressings for a client who has 2 Penrose drains near an abdominal incision. Which of the following adhering devices is the best choice for the nurse to use to decrease skin irritation? A. Abdominal binder B. Montgomery straps C. Hypoallergenic tape D. Plastic tape

B. Montgomery straps

As part of a neurological examination, a nurse instructs a client to keep his eyes closed, places an object in his hand, and asks him to identify the object. Which of the following abilities is the nurse evaluating with this technique? A. Gustation B. Stereognosis C. Proprioception D. Kinesthesia

B. Stereognosis

A nurse is caring for a client who has a stage III pressure ulcer on the heel. When preparing to irrigate the wound, which of the following actions should the nurse take first? A. Obtain the prescribed irrigation solution B. Don personal protective equipment C. Check the client's pain level D. Place a waterproof pad under the client's extremity

C. Check the client's pain level

A nurse is performing an admission assessment for a client. Which of the following responses by the nurse reflects the communication technique of clarifying? A. "Now that we have talked about your medications, let's talk about your pain." B. "Are you having other symptoms?" C. "It sounds like your pain is intermittent." D. "It seems as though you have really had a rough time these past few weeks."

C. "It sounds like your pain is intermittent."

A nurse is providing teaching about food choices to a client who has a prescription for a clear liquid diet. Which of the following selections by the client indicates an understanding of the teaching? A. Cream of rice B. Cottage cheese C. Gelatin D. Ice Cream

C. Gelatin

A nurse in a same-day procedure unit is caring for several clients who are undergoing different types of procedures. The nurse should anticipate that the client who has which of the following devices can safely undergo magnetic resonance imaging (MRI)? A. artery stents B. Aneurysm clip C. Hearing aids D. Automated internal defibrillator

C. Hearing aids

A nurse is preparing to administer a tap water enema to a client. Which of the following actions should the nurse take? A. Raise the enema bag if the client experiences cramping B. Lubricate 2.54 cm (1 in) of the tip of the rectal tube prior to insertion C. Place the client in a left Sims' position D. Don sterile gloves prior to the procedure

C. Place the client in a left Sims' position

A nurse is planning care for a client who is postoperative and has a history of poor nutritional intake. Which of the following actions should the nurse include in the plan of care to promote wound healing? A. Limit total caloric intake to 25 kcal/kg of body weight B. Provide an intake of 500 mg/day of vitamin E C. Limit fluid intake to 20 mL/kg of body weight per day D. Provide a protein intake of 1.5 g/kg of body weight per day

D. Provide a protein intake of 1.5 g/kg of body weight per day

During the completion of a health history with a nurse, a client reports intermittent chest pain for the past week. Which of the following questions is the nurse's priority? A. "Did you report the chest pain episodes to your physician?" B. "Is there a history of heart disease in your family?" C. "Have you had this pain before?" D. "Can you tell me what the pain felt like and show me exactly where it was?"

D. "Can you tell me what the pain felt like and show me exactly where it was?"

A nurse is caring for a client who had a mastectomy and has a self-suction drainage evacuator in place. Which of the following actions should the nurse take to ensure proper operation of the device? A. Irrigate the tubing with sterile normal water once during each shift B. Cleanse the opening with soap and water after emptying C. Maintain the tubing above the level of the surgical incision D. Collapse the device to remove air after emptying

D. Collapse the device to remove air after emptying

A nurse is caring for a client who is unstable and has vital signs measured every 15 minutes by an electronic blood pressure machine. The nurse notices the machine begins to measure the blood pressure at varied intervals, and the readings are inconsistent. Which of the following actions should the nurse take? A. Turn on the machine every 15 min to measure the client's blood pressure. B. Record only the blood pressure readings needed for 15-min intervals. C. Obtain manual and automatic readings and compare them. D. Disconnect the machine and measure the blood pressure manually every 15 min.

D. Disconnect the machine and measure the blood pressure manually every 15 min.

A nurse is caring for a client who has a hearing impairment. Which of the following interventions should the nurse use when speaking with the client? A. Explain that it is against policy to share access codes and refer the resident to his supervisor. B. Exaggerate lip movements C. Speak Loudly D. Face the client when speaking

D. Face the client when speaking

A nurse is assessing a client who is postoperative. Which of the following findings should the nurse identify as an indication that the client is experiencing pain? A. Diarrhea B. Pupillary constriction C. Flushing D. Grimacing

D. Grimacing

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? A. I'll limit pushing the button so I don't get an overdose B. If I push the button and still have pain after 2 minutes, I'll push it again C. I'll ask my niece to push the button when I am sleeping D. I can still use my transcutaneous electrical nerve stimulation unit while I'm pushing the PCA button

D. I can still use my transcutaneous electrical nerve stimulation unit while I'm pushing the PCA button

A nurse is changing the dressings for a client who is 3 days postoperative following a cholecystectomy. The nurse observes yellow, thick drainage on the dressing. The nurse should document this finding as which of the following types of drainage? A. Sanguineous exudate B. Serous exudate C. Serosanguineous exudate D. Purulent Exudate

D. Purulent Exudate

A nurse is planning to obtain the vital signs of a 2-year-old child who is experiencing diarrhea and may have a right ear infection. Which of the following routes should the nurse use to obtain the child's temperature? A. Rectal B. Tympanic C. Oral D. Temporal

D. Temporal

A nurse is teaching an assistive personnel (AP) how to obtain a capillary finger-stick blood sample. Which of the following actions by the AP requires the nurse to intervene? A. Elevating the finger above heart level B. Rubbing the fingertip with an alcohol pad C. Puncturing the side of the fingertip D. Wrapping the finger in a warm cloth

A. Elevating the finger above heart level

A nurse is talking with the parent of a preschool-aged child who tells the nurse, "My child has suddenly become disinterested in certain foods." Which of the following statements should the nurse make? A. "During this phase, feed your child anything that she will eat." B. "Increase the amount of calories and water your child consumes." C. "Keep a diary of the foods your child eats each day." D. "Provide a large variety of fruit juices for your child to choose from."

C. "Keep a diary of the foods your child eats each day."

A nurse is preparing to administer an otic antibiotic to an adult client who has otitis media. Which of the following actions should the nurse plan to take? A. Hold the dropper 1 cm (0.5 in) above the ear canal during administration B. Apply pressure to the nasolacrimal duct following administration C. Place a cotton ball into the inner ear canal for 30 minutes following administration D. Straighten the ear canal by pulling the auricle down and back prior to administration

A. Hold the dropper 1 cm (0.5 in) above the ear canal during administration

A nurse is performing a breast examination for a female client. Which of the following techniques should the nurse use first? A. Inspect both breasts simultaneously B. Squeeze the nipples C. Palpate the breast and tail of Spence D. Palpate the axillary lymph nodes

A. Inspect both breasts simultaneously

A nurse is providing teaching to a client with heart failure about reducing his daily intake of sodium. Which of the following factors is the most important in determining the client's ability to learn new dietary habits? A. The involvement of the client in planning the change B. The emphasis the provider places on the dietary changes C. The learning theory the nurse uses to teach the dietary changes D. The extent of the dietary changes planned for the client

A. The involvement of the client in planning the change

A nurse is caring for a client who has cancer and is experiencing pain. The nurse should implement which of the following interventions to assist the client with pain relief? A. Encourage the client to listen to soft music B. Instruct the client to practice tai chi C. Place a jasmine-scented air freshener in the client's room D. Offer the client ginger tea

A. Encourage the client to listen to soft music

A new resident provider asks the charge nurse for an access code to review clients' online records. The resident is not scheduled to attend the facility's orientation computer class until next week. Which of the following actions should the nurse take? A. Explain that it is against policy to share access codes and refer the resident to his supervisor. B. Access the clients' online data and monitor the resident as he reads them. C. Access the online system and allow the resident to locate clients' data. D. Ask each client to give permission for the resident to access medical records.

A. Explain that it is against policy to share access codes and refer the resident to his supervisor.

A nurse is preparing to provide chest physiotherapy for a client who has left lower lobe atelectasis. Which of the following actions should the nurse plan to take? A. Place the client in the Trendelenburg position B. Perform percussions directly over the client's bare skin C. Use a flattened hand to perform percussions D. Remind the client that chest percussions can cause mild pain

A. Place the client in the Trendelenburg position

A nurse is providing nutrition counseling to a middle-aged adult client who has a sedentary job. Which of the following factors should the nurse consider? A. The risk of eating disorders increases at this age. B. The client's basal metabolic rate could decrease. C. Daily vitamins will be become necessary to meet nutritional needs. D. Limiting the intake of fish to once per week reduces cardiovascular risks.

B. The client's basal metabolic rate could decrease.

A nurse is implementing cold therapy for a client who has an ankle sprain. Which of the following actions should the nurse take? A. Apply a cold pack to the edematous area B. Check capillary refill before applying an ice pack to the affected area C. Half-fill an ice pack with crushed ice D. Apply an ice pack for 60 min intervals

B. Check capillary refill before applying an ice pack to the affected area

A nurse is planning care for a young adult client who has a terminal illness. Which of the following concepts of death should the nurse consider for this client? A. Death is unacceptable under any circumstances. B. Magical thinking helps avoid thoughts of death. C. Death is viewed as an interruption of what might have been. D. Death is a natural consequence of a deteriorating body.

C. Death is viewed as an interruption of what might have been.

A nurse is caring for 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 that the client is in which of the following stages of grief as defined by Kubler-Ross? A. Anger B. Bargaining C. Depression D. Acceptance

C. Depression

A nurse is administering a cleansing enema to a client who is scheduled for a diagnostic procedure. Which of the following actions should the nurse take? A. Lubricate up to 3.2 cm (1.25 in) of the tip of the rectal tube B. Position the client on the right side C. Insert the tip of the tubing 8 cm (3.1 in) D. Hold the enema container 61 cm (24 in) above the rectum

C. Insert the tip of the tubing 8 cm (3.1 in)

A nurse delegates the collection of a client's temperature to an assistive personnel (AP). The nurse notes in the documentation that the AP obtained the client's axillary 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? A. Right task B. Right circumstance C. Right person D. Right communication

D. Right communication