RN Fundamentals Online Practice 2019 A
A nurse is assessing a client's readiness to learn about insulin administration. Which of the following statements should the nurse identify as an indication that the client is ready to learn?
"I can concentrate best in the morning."
A nurse is caring for a client who asks about the purpose of advance directives. Which of the following statements should the nurse make?
"They indicate the form of treatment a client is willing to accept in the event of a serious illness."
A nurse is assessing an older adult client's risk for falls. Which of the following assessments should the nurse use to identify the client's safety needs?
- pupil clarity - visual fields - visual acuity
A nurse is providing discharge teaching to a client about self-administering heparin. Which of the following instructions should the nurse include in the teaching? 1. Insert the needle at a 15° angle. 2. Aspirate for blood return prior to administration. 3. Administer the medication into the abdomen. 4. Massage the site following the injection.
3 The nurse should instruct the client to administer the medication into the abdomen at least 5.08 cm (2 in) from the umbilicus. The client should pinch or spread the skin at the injection site to administer the medication into the subcutaneous tissue.
A nurse is preparing to apply a dressing for a client who has a stage 2 pressure InjuryWhich of the following types of dressing should the nurse use ? 1. Alginate 2. Gauze 3. Transparent 4. Hydrocolloid
4Hydrocolloid dressings promote healing in stage 2 pressure injuries by creating a moist wound bed.
A nurse is caring for a client who has a sodium level of 125 mEq/L. Which of the following findings should the nurse expect?
Abdominal cramping Tachycardia is manifestation of hypovolemia along with hyponatremia
A nurse is caring for a client who is postoperative. When the nurse prepares to change her dressing, she says, "Every time you change my bandage, it hurts so much." Which of the following interventions is the nurse's priority action?
Administer paln medication 45 min before changing the client's dressing
A nurse is caring for a client who has a respiratory infection. Which of the following techniques should the nurse use when performing nasotracheal suctioning for the client?
Apply intermittent suction when withdrawing the catheter.
A nurse is preparing to administer an injection of an opioid medication to a client. The nurse draws out 1 of the medication from a 2 ml vial Which of the following actions should the nurse take?
Ask another nurse to observe the medication wastage
A nurse receives report about a client who has 0.9% sodium chloride infusing IV at 125mL / h * r . When the nurse performs the initial assessment, he notes that the client has received only 80 over the last 2 hr. Which of the following actions should the nurse take first?
Check the IV tubing for obstruction
A nurse is responding to a call light and finds a client lying on the bathroom floor. Which of the following actions should the nurse take first?
Check the client for injuries The first action the nurse should take when using the nursing process is to assess the client for injuries.
A nurse is caring for a client who requires an NG tube for stomach decompressionWhich of the following actions should the nurse take inserting the NG tube?
Have the client take sips of water to promote insertion of the NG tube into the esophagus
A nurse is caring for a client who is postoperative following a knee arthroplasty and requires the use of thigh-length sequential compression sleeves. Which of the following actions should the nurse take?
Make sure two fingers can fit under the sleeves
A nurse reviewing a client's fluid and electrolyte status. Which of the following findings should the nurse report to the provider?
Potassium 5.4 mEq/L
A nurse is caring for a client who is expressing anger over his diagnosis of colorectal cancer. What should the nurse do?
Reassure the client that this is an expected response to grief
A nurse is reviewing a evidence based practice principles about administration of oxygen therapy with a newly licensed nurse . Which of the following actions should the nurse include ?
Regulate oxygen via nasal canal at a flow rate of no more then 6L/ min
A nurse is talking with the partner of a client who has dementia. The client's partner expresses frustration about finding time to manage household responsibilities while caring for their partner. The nurse should identify that the partner experiencing which of the following types of role-performance stress? Role ambiguity Sick role Role overload Role conflict
Role overload
A nurse is lifting a bedside cabinet to move it closer to a client who is sitting in a chair. To prevent self-injury, which of the following actions should the nurse take when lifting this object?
Stand close to the cabinet when lifting it. DO NOT bend at the waist, keep his feet close together, or use his back muscles for lifting
A nurse is using an open irrigation technique to irrigate a client's indwelling urinary catheter. Which of the following actions should the nurse take? Place the client in a side-lying position. Instill 15 mL of irrigation fluid into the catheter with each flush. Subtract the amount of irrigant used from the clients urine output. Perform the irrigation using a 20-mL syringe.
Subtract the amount of irrigant used from the client's urinary output (open irrigation requires instilling 30-40 mL of irrigation fluid)
A nurse is evaluating a client's use of a cane. Which of the following actions should the nurse identify as an indication of correct use?
The client holds the cane on the stronger side of the body Proceeding with Ambulation: 1. the patient stands with weight evenly distributed between the feet and the cane 2. The cane is held on the patients stronger side and is advanced 4-12in (10-30cm) 3. Supporting weight on the stronger leg, advance the weaker leg forward, parallel with the cane 4. Supporting weight on the weaker leg, advance the stronger leg forward, ahead of the cane 5. The weaker leg is moved forward until even with the stronger leg along with advancement of the cane
A nurse is caring for a client who has a terminal illness and is approaching death. The client is short of breath and has noisy respirations from secretions in their airway. Which of the following actions should the nurse take?
Turn the client every 2 hours
A is teaching a client and family how to care for the client's tracheostomy at home. Which of the following instructions should the nurse include in the teaching?
Use Tracheostomy covers when outdoors. Rationale: Tracheostomy covers protect the clients airway from cold air, dust, and other airborne particles.
A nurse manager is preparing to review medication documentation with a group of newly licensed nurses. Which of the following stateme should the nurse manager plan to include in the teaching?
Use the complete name of the medication magnesium sulfate
A nurse on a medical-surgical unit is caring for a client who has a new prescription for wrist restraints. Which of the following should the nurse take? a) pad the clients wrist before applying the restraints b) evaluate the clients circulation every 8hr after application c) remove the restraints every 4hr to evaluate the clients status d) secure the restraint ties to the beds side rails
a) pad the clients wrist before applying the restraints
A nurse is admitting a new client. Which of the following actions should the nurse take while performing medication reconciliation? a) verify the clients name on their identification bracelet with the medication administration record b) call the pharmacy to determine whether the clients medications are available c) compare the clients home medications with the providers prescriptions d) place the clients home medication bottles in a secure location
c) compare the clients home medications with the providers prescriptions
A nurse is assessing a client who reports increased pain following physical therapy. Which of the following questions should the nurse ask when assessing the quality of the client's pain? a. "Is your pain constant or intermittent?" b. "What would you rate your pain on a scale of 0 to 10?" c. "Does the pain radiate?" d. "Is your pain sharp or dull?"
d. Is your pain sharp or dull?
A nurse is caring for a client who has pharyngeal diptheria. Which of the following types of transmission precautions should the nurse initiate?
droplet
A nurse is admitting a client who is having an exacerbation of heart failure. In planning this client's care, when should the nurse initiate discharge planning?
during the admission process
A nurse is caring for a young child who is prescribed a blood transfusion. The parents have refused treatment due to religious beliefs. Which of the following actions should the nurse take
examine personal values about the issue
A nurse in a long-term care facility is caring for a client who dies during the nurse's shift. Identify the sequence in which the nurse should perform the following steps. -Place a name tag on the body -Obtain the pronouncement of death from the provider -Remove tubes and indwelling lines -Wash the client's body -Ask the client's family members if they would like to view the body
-Obtain the pronouncement of death from the provider -Remove tubes and indwelling lines -Wash the client's body -Ask the client's family members if they would like to view the body -Place a name tag on the body
A nurse is preparing an education program for staff about advocacy. which of the following information should the nurse include? A) Advocacy ensures client safety, health and rights B) Advocacy ensure that nurses are able to explain their own actions C) Advocacy ensure the nurses follow through on their promise to clients D) Advocacy enthuses fairness in client care and use of resources
A) Advocacy ensures client safety, health and rights
A nurse is preparing to administer enoxaparin subcutaneously to a client. Which of the following actions should the nurse take?
Administer the medication with the needle at a 45° angle. Because A nurse is using an open irrigation technique to irrigate a client's indwelling urinary catheter.
A nurse is preparing a change-of-shift report. Which of the following tools or documents should the nurse use to communicate continuity of care? A) Critical pathway B) Situation, background, assessment, and recommendation (SBAR) C) Transfer report D) Medication administration record (MAR)
B) Situation, background, assessment, and recommendation (SBAR)
The nurse is admitting a client who has an abdominal wound with a large amount of purulent drainage. Which type of transmission precautions should the nurse initiate?
Contact precautions (Major wound infections require contact precautions, which means the nurse should admit the client to a private room. All caregivers should wear a gown and gloves during direct contact with patient)
A nurse is administering an otic medication to an older adult client. Which of the following actions should the nurse take to ensure that the medication reaches the inner ear? a) press gently on the tragus of the clients ear b) pack a small piece of cotton deep into the clients ear canal c) move the clients auricle down and back toward her head d) tilt the clients head backward for 5 min
a) press gently on the tragus of the clients ear
A nurse is planning strategies to manage time effectively for client care. Which of the following strategies should the nurse implement? a) combine client care tasks when caring for multiple clients b) wait until the end of the shift to document client care c) use the planning step of the nursing process to prioritize client care delivery d) allow for interruption in tasks to discuss client care issues with colleagues
c) use the planning step of the nursing process to prioritize client care delivery
A nurse is planning care for a client who has had stroke resulting in aphasia and dysphagia. Which of the following task should the nurse assign to an AP? Select all that apply Assist the client with partial bed bath Measure the client's BP AFTER NURSE ADMINISTERS AN antihypertensive medication. Test the clients swallowing ability by providing thickened liquids Use communication board to ask what the client wants for lunch Irrigate the clients in dealing urinary catheter
Assist the client with partial bed bath Measure the client's BP AFTER NURSE ADMINISTERS AN antihypertensive medication. Use communication board to ask what the client wants for lunch
A nurse is educating a client who has a terminal illness about declining resuscitation in a living will. The client asks, "What would happen if I arrived at the emergency department and I had difficulty breathing?" Which of the following responses should the nurse make? A. "We would consult the person appointed by your health care proxy to make decisions." B. "We would give you oxygen through a tube in your nose." C. You would be unable to change your previous wishes about your care." D. We would insert a breathing tube while we evaluate your condition."
B. "We would give you oxygen through a tube in your nose."
A nurse is caring for a group of clients. Which of the following actions should the nurse take to prevent the spread of infection? A. Carry a client's soiled linens out of the room in a mesh linen bag. B. Place a client who has tuberculosis in a room with negative-pressure airflow C. Provide disposable plates and utensils for a client who is HIV-positive. D. Dispose of a client's blood-saturated dressing in a trash bag inside a second trash bag.
B. Place a client who has tuberculosis in a room with negative-pressure airflow
A home health nurse is performing a follow-up visit for a client who has a gastrostomy tube through which they receive intermittent feedings and medications. The client has recently developed diarrhea. Which of the following findings should the nurse identify as a possible cause of the diarrhea? a) the client is receiving formula at room temperature b) the feedings infuse at a slow, continuous drip over 8 hr each night c) the clients caregiver washes out the feeding bag with warm water once every 24 hr d) the clients caregiver flushes the tube with water before and after administering medications
c) the clients caregiver washes out the feeding bag with warm water once every 24 hr Feeding bags should be washed out after each feeding and replaced with a new feeding bag every 24 hr to prevent bacterial contamination
A nurse is caring for a client who is postoperative and is exhibiting signs of hemorrhagic stroke. The nurse notifies the surgeon, who tells the nurse to continue to measure the clients vital signs every 15 min and to report back in 1 hr. Which of the following actions should the nurse take next? a) document the providers statement in the medical record b) complete an incident report c) consult the facility's risk manager d) notify the nursing manager
d) notify the nursing manager
A nurse in a provider's office is assessing the deep tendon reflexes of a client. Which of the following images should the nurse identify as indicating the correct technique for eliciting the client's patellar reflex?
tap just bellow the kneecap
A nurse is caring for a client who has diarrhea due to shigella. Which of the following precautions should the nurse implement for this client? 1. Have the client wear a mask when receiving visitors. 2. Limit the client's time with visitors to no more than 30 min per day. 3. Assign the client to a room with negative-pressure airflow exchange. 4. Wear a gown when caring for the client.
4 Wear a gown when caring for the client. The nurse should implement contact precautions for a client who has shigella to prevent the transmission of the bacteria. The nurse should wear a gown when providing care for a client who requires contact precautions due to the risk of contact with bodily fluids and contaminated surfaces.
Nurse performing a skin assessment for a client who expresses concern about skin cancer. What findings should the nurse identify as a potential indication of a skin malignancy?
A mole with an asymmetrical appearance
A nurse is caring for a client who is postoperative and refuses to use an incentive spirometer following a major surgery. Which of the following actions is the nurses priority? A. request that a respiratory therapist discuss the technique for incentive spirometry with the client B. determine the reasons why the client is refusing to use the incentive spirometer C. document the clients refusal to participate in health restorative activities. D. Administer a pain medication to the client
B. determine the reasons why the client is refusing to use the incentive spirometer
A nurse is caring for a client who has an aggressive form of prostate cancer. The provider briefly discusses treatment options and leaves the client's room. When the nurse asks the would like discuss any concerns, the declinesof the following statements should the nurse make?
I am available to talk if you should change your mind
A client who is postoperative is verbalizing pain as a 2 on a pain scale of to 10. Which of the following statements should the nurse identify as ar indication that the client understands the preoperative teaching she received about pain management?
It might help me to listen to music while I'm lying in bed
nurse is talking with an older adult client who is contemplating retirement. The client states, "I keep thinking about how much I enjoy my job. I'm not sure I want to retire." Which of the following responses should the nurse make?
Let's talk about how the change in your hob status will affect you.
A nurse is auscultating the anterior chest of a client who was newly admitted to a medical-surgical unit, Listen to the audio clip of what the nurse auscultates through the stethoscope and identify the type of breath sounds. (Click on the audio button to listen to the clip.)
Normal breath sounds
A nurse is caring for a client who has dementia. Which of the following interventions should the nurse take to minimize the risk for injury to the client? a) use a bed exit alarm system b) raise four side rails while the client is in bed c) apply one soft wrist restraint d) dim the lights in the clients room
a) use a bed exit alarm system
a nurse is caring for a client who has herpes zoster and asks the nurse about the use of complementary and alternative therapies for pain control. the nurse should inform the client that his condition is a contraditicion for which?
acupuncture- contradiction with someone with any skin disease, to prevent and open portal on the skins surface, which could increase furth infection
A nurse is caring for a client who has a terminal illness and is at the end of life. The nurse should recognize that which of the following statements by the client's partner indicates effective coping? a) "I am not worried because I still have hope that he will be okay" b) "I am relying on support from our family during this time" c) "We can plan our family reunion once he recovers and comes home" d) "We don't see any reason to start discussing funeral arrangements right now"
b) "I am relying on support from our family during this time"
A nurse is providing discharge instructions to a client who will be using a walker. Which of the following client statements indicates an understanding of the teaching? a) "I can place an extension cord across my living room to plug in my television" b) "I will hire someone to trim the tree that hangs low over the stairs of my front porch" c) "I will place my alarm clock on my bedroom dresser across the room" d) "I will replace the old throw rug in my kitchen with a new one"
b) "I will hire someone to trim the tree that hangs low over the stairs of my front porch"
A nurse is assessing four adult clients. Which of the following physical assessment techniques should the nurse use? a) use the Face, Legs, Activity, Cry, and Consolability (FLACC) pain rating scale for a client who is experiencing pain b) ensure the bladder of the blood pressure cuff surrounds 80% of the clients arm c) obtain an apical heart rate by auscultating at the third intercostal space left of the sternum d) palpate the clients abdomen before auscultating bowel sounds
b) ensure the bladder of the blood pressure cuff surrounds 80% of the clients arm
A nurse is initiating a protective environment for a client who has had an allogenic stem cell transplant. Which of the following precautions should the nurse plan for this client? a) make sure the clients room has at least six air exchanges per hour b) make sure the client wears a mask when outside her room if there is construction in the area c) place the client in a private room with negative-pressure airflow d) wear an N95 respirator when giving the client direct care
b) make sure the client wears a mask when outside her room if there is construction in the area
A nurse is planning to insert a peripheral IV catheter for an older adult client. Which of the following actions should the nurse plan to take? a) insert the catheter at a 45º angle b) place the clients arm in a dependent position c) shave excess hair from the insertion site d) initiate IV therapy in the veins of the hand
b) place the clients arm in a dependent position because the veins will dilate due to gravity
A nurse is performing a home safety assessment for a client who is receiving supplemental oxygen. Which of the following observations should the nurse identify as proper safety protocol? a) the client uses a wool blanket on their bed b) the client identifies the location of a fire extinguisher c) the client stores an extra oxygen tank on its side under their bed d) the client has a weekly inspection checklist for oxygen equipment
b) the client identifies the location of a fire extinguisher the client uses nonacetone nail polish remover
A nurse is assessing a client who has required bed rest for the past month. Which of the following findings should the nurse identify as an indication that the client has developed thrombophlebitis? a) bladder distention b) decreased blood pressure c) calf swelling d) diminished bowel sounds
c) calf swelling
A nurse is administering 1 L of 0.9% sodium chloride to a client who is postoperative and has fluid volume deficit. Which of the following changes should the nurse identify as an indication that the treatment was successful? a) increase in hematocrit b) increase in respiratory rate c) decrease in heart rate d) decrease in capillary refill time
c) decrease in heart rate
