Fundamentals Study Guide 1

A nurse is caring for a client who decides not to have surgery despite significant blockages in his coronary arteries. The nurse understands that this client's choice is an example of which of the following ethical princple?

A nurse is preparing to perform endotracheal suctioning for a client. Which of the following are appropriate guidelines for the nurse to follow? (SATA)

A nurse is caring for a client who is having difficulty breathing. The client is lying in bed and is already receiving oxygen therapy via nasal cannula. Which of the following interventions is the nurse's priority?

A nurse is assessing a client who has an acute respiratory infection that puts her at risk for hypoxemia. Which of the following findings are early indications that should alert the nurse that the client is developing hypoxemia? (SATA)

A nurse offers pain medication to a client who is post-op prior to ambulation. The nurse understands that this aspect of care delivery is an example of which of the following ethical principles?

A nurse is instructing a group of nursing students about the responsibilities involved with organ donation and procurement. When the nurse explains that all clients waiting for a kidney transplant have to meet the same qualifications, the students should understand that this aspect of care delivery is an example of which of the following ethical principles?

A nurse questions a medication prescription as too extreme in light of the client's advanced age and unstable status. The nurse understands that this action is an example of the following ethical principles?

A nurse is instructing a group of nursing students about how to know and what to expect when ethical dilemmas arise. Which of the following situations should the students identify as an ethical dilemma?

A nurse observes an AP reprimanding a client for not using the urinal properly. The AP tells him she will put a diaper on him of he does not use the urinal more carefully next time. Which f the following torts is the AP committing?

An adult client who is competent tells the nurse that he is thinking about leaving the hospital against medical advice. The nurse believes that this is not in the client's best interest, so she administers a PRN sedative med the client has not requested. Which of the following types of tort has the nurse committed?

Which of the following statements by the client indicates to the nurse that he understands advance directives?

A client is about to undergo an elective procedure. Which of the following actions are appropriate for the nurse who is providing pre-op care regarding informed consent? (SATA)

A nurse has noticed several occasions in the past week when another nurse on the unit seemed drowsy and unable to focus on the issue at hand. Today, she found the nurse asleep in a chair in the break room when she was not on a break. Which of the following actions should the nurse take?

A nurse is caring for a client who has a tracheostomy. Which of the following actions should the nurse take each time he provides tracheostomy care? (SATA)

A provider is discharging a client with a prescription for home oxygen therapy via nasal cannula. Client and family teaching by the nurse should include which of the following instructions? (SATA)

A nursing instructor is explaining the various stages of the lifespan to a group of nursing students. The nurse should offer which of the following behaviors by a young adult as an example of accomplishing Erikson's tasks for psychosocial development during middle adulthood?

A nurse is collecting data to evaluate a middle adult's psychosocial development. The nurse should expect middle adults to demonstrate which of the following capabilities? (SATA)

A nurse is reviewing the CDC's immunization recommendations with a middle adult client. Which of the following recommendations should the nurse include in this discussion? (SATA)

A nurse is counseling a middle adult who describes having difficulty dealing with several issues. Which of the following problems the client verbalized should the nurse identify as the priority for further assessment and intervention?

A nurse is caring for a client diagnosed with severe acute resp. syndrome (SARS). The nurse is aware that health care professionals are required to report communicable and infectious diseases. Which of the following illutrate the rationale for reporting? (SATA)

A nurse is contributing to the plan for a client who is being admitted to the facility with a suspected diagnosis of pertussis. Which of the following should the nurse include in the plan of care? (SATA)

A nurse is caring for a client who presents with linear clusters of fluid-containing vesicles with some crustings. Which of the following should the nurse suspect?

A nurse is caring for a client who reports a severe sore throat, pain when swallowing, and swollen lymph nodes. The client is experiencing which of the following stages of infection?

A nurse educator is reviewing with a newly hired nurse the difference in clinical manifestations of a localized versus a systemic infection. The nurse indicates understanding when she states that which of the following are clinical manifestations of a systemic infection? (SATA)

By the second post-op day, a client has not achieved satisfactory pain relief. Based on this evaluation, what should the nurse do next according to the nursing process?

A nursing instructor is reviewing the steps of the nursing process with a group of nursing students. The students should identify which of the following data as objective? (SATA)

A nursing instructor is reviewing which actions nurses can initiate without a provider's prescription with a group of nursing students. The students should identify which of the following interventions as nurse-initiated? (SATA)

During evaluation, the nurse must gather info about the client to

A nursing student is reporting to the clinical instructor about the care she gave to a client. She states: "The client said his leg pain was back, so I checked his medical record, and he last received his pain medication 6 hr ago. The prescription reads every 4 hr PRN for pain, so I decided he needs it. I asked the unit nurse to observe me preparing and administering it. I checked with the client 40 min later, and he said his pain is going away." The instructor should inform the student that she left out which of the following steps of the nursing process?

A nurse is caring for a client whose partner passed away 4 months ago and who has been recently diagnosed with diabetes mellitus. He is tearful and states, "How could you possibly understand what I am going through?" Which of the following is an appropriate response by the nurse?

A nurse is caring for a client awaiting transport to the surgical suite for a coronary artery bypass graft. Just as the transport team arrives, the nurse takes the client's vital signs and notes an elevation in blood pressure and heart rate. The nurse should recognize this response as which part of the general adaptation syndrome (GAS)?

A nurse is caring for a client who has a new diagnosis of type 2 diabetes mellitus. Which of the following nursing interventions for stress, coping, and adherence to the treatment plan would be appropriate at this time? (SATA)

A nurse is caring for a client who has left-sided hemipelgia resulting from a cerebrovascular accident. The client works as a carpenter and is now experiencing a situational role change based on physical limitations. The client is the primary wage earner in the family. Which of the following best describes the client's role problem?

Which of the following approaches should the nurse use when working with a family using am open structure for coping with crisis?

A nurse is caring for a client who is at high risk for aspiration. Which of the following is an appropriate nursing intervention?

Which of the following is the body's priority energy source?

A nurse is caring for a client who is on a low-residue diet. The nurse should expect to see which of the following foods on the client's meal tray?

A nurse in a senior center is counseling a group of older adults about their nutritional needs and considerations. Which of the following info should the nurse include? (SATA)

A nurse is caring who has terminal lung cancer. The nurse observes the client's family assisting with all ADLs. Which of the following rationales for self-care should the nurse communicate to the family?

A nurse is caring for a client who has stage 4 lung cancer and id 3 days post-op following a wedge resection. The client states, "I told myself that I would go through and quit smoking, if I could just live long enough to attend my daughter's wedding." Based on Kubler-Ross' Five Stages of Grief, which stage is the client experiencing?

A nurse is consoling the partner of a client who just expired after a ling battle with liver cancer. The partner is displaying grief and states, "I hate him for leaving me." Which of the following statements by the nurse successfully facilitate mourning for the grieving partner? (SATA)

A nurse is caring for a client who has a terminal illness. Death is expected within 24 hr. The client's family is at the bedside and asks the nurse what are anticipated clinical findings at this time. Which of the following is an appropriate response by the nurse?

A nurse assisting a newly licensed nurse with postmortem care of a client. The family wishes to view the body. Which of the following statements by the newly licensed nurse indicate an understanding of the procedure? (SATA)

A nurse is caring for a client who recently has a cerebrovascular accident and has aphasia. Which of the following interventions should the nurse use to promote communication with this client? (SATA)

A nurse is caring for a client who had an amphetamine overdose and has sensory overload. Which of the following interventions should the nurse implement?

A nurse is caring for a client who reports difficulty hearing. Which of the following assessments findings indicate a sensorineural hearing loss in the left ear? (SATA)

A nurse is reviewing instructions with a client who is hearing impaired and has just started wearing hearing aids. Which of the following statements by the client indicates understanding of the instructions?

A nurse is caring for a client who has several risk factors for hearing loss. As the nurse reviews the client's med history, which of the following meds the client takes should the nurse to a further risk for ototoxicity? (SATA)

A nurse is caring for a cient who has been sitting in a chair for 3 hr. Which of the following problems is the client at risk for developing?

A nurse is caring for a client who is on bed rest. Which of the following interventions should the nurse implement to maintain the patency of the client's airway?

A nurse is caring for a client who is post-op. Which of the following nursing interventions reduces the risk of thrombus development? (SATA)

A nurse is instructing a client who is post-op about the sequential compression device the provider has prescribed. Which of the following client statements should indicate to the nurse that the client understands the teaching?

To promote the safe use of a cane for a client who is recovering from a minor musculoskeletal injury of the left lower extremity, which of the following instructions should the nurse provide? (SATA)

A nurse is assessing the pain level of a client who has come to the emergency department reporting severe abdominal pain. The nurse asks the client whether he has nausea and has been vomiting. The nurse is assessing which of the following?

A nurse is assessing a client who is reporting pain despite analgesia. The nurse can best assess the intensity of the client's pain by

A nurse is obtaining a history from a client who has pain. The nurse's guiding principle throughout this process should be that

A nurse is caring for a client who is receiving morphine via PCA infusions device after abdominal surgery. Which of the following statements indicates that the client knows how to use the device?

A nurse is monitoring a client who is receiving opioid analgesic for adverse effects of the meds. Which of the following effects should the nurse anticipate? (SATA)

A nurse in a provider's office is caring for a client who states that, for the past week, she has felt tired during the day and cannot sleep at night. Which of the following questions should the nurse ask when collecting data about the client's difficulty sleeping? (SATA)

A nurse is talking with a client about ways to help him sleep and rest. Which of the following recommendations should the nurse give to th client to promote sleep and rest? (SATA)

A nurse is caring for an older adult client who has been following the facility's routine and bathing in the morning. However, at home, she always takes a warm bath just before bedtime. Now she is having difficulty sleeping at night. Which of the following actions should the nurse take first?

A nurse is preparing a presentation about sleep hygiene. When explaining rapid eye movement (REM) sleep. Which of the following characterisitics should the nurse include? (SATA)

A nurse is instructing a client who has a new diagnosis of narcolepsy about measures that might help with self-management. Which of the following client statements understanding of the instructions?

A nurse is caring for a client who is 1 day post-up following a total knee arthroplasty. The client states his pain level is 10. After reviewing the client's medication administration record, which of the following meds should the nurse administer?

A nurse is teaching a client about taking multiple oral meds at home to include time-release capsules, liquid meds, enteric-coated pills, and narcotics. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is teaching a client how to administer meds through a jejunostomy tube. Which of the following instructions should the nurse include in the teaching?

A nurse educator is teaching a module on pharmacokinetics to a group of newly licensed nurses. Which of the following statements by a newly licensed nurse indicates an understanding of the first-pass effect?

A nurse is teaching an adult client how to administer ear drops. Which of the following statements by the client indicates understanding of the proper technique?

A nurse prepares an injection of morphine (Duramorph) to administer to a client who reports pain. Prior to administering the meds, the nurse is called to another room to assist another client onto a bedpan. She asks a second nurse to give the injection. Which of the following actions should the nurse take?

A nurse is preparing to administer a med to a client. The med was scheduled for administration at 0900. Which of the following are acceptable administration times for this medication?

A nurse is working with a newly hired nurse who is administering meds to clients. Which of the following actions by the newly hired nurse indicates an understanding of med error prevention?

A nurse educator is teaching a module on safe med administration to newly hired nurses. Which of the following statements by a newly hired nurse indicates understanding of the nurse's responsibility when implementing medication therapy? (SATA)

A nurse is preparing to administer digoxin (Lanoxin) to a client who states, "I don't want to take that mediation. I don not want one more pill." Which of the following responses by the nurse is appropriate in this situation?

A nurse is caring for an 82-year-old client in the emergency department who has an oral body temp of 101F, a pulse rate of 114/min, and a resp rate f 22/min. He is restless and his skin is warm. Which of the following are appropriate nursing interventions for this client? (SATA)

A nurse is instructing an AP in caring for a client who has a low platelet count as a result of chemotherapy. Which of the following is the nurse's priority instruction for measuring vital signs for this client?

A nurse is instructing a group of nursing students in measuring a client's respiratory rate. Which of the following guidelines should the nurse include? (SATA)

A nurse who is admitting a client who has a fractured femur obtains a BP reading of 140/94. The client denies any history of hypertension. Which of the following actions should the nurse take next?

A nurse is performing an admission assessment on a client. When measuring her vital signs, the nurse finds that her radial pulse rate 68/min and her simultaneous apical pulse rate is 84/min. What is the client's pulse deficit?

A nurse is caring for a client who will perform fecal occult blood testing at home. Which of the following info should the nurse include when explaining the procedure to the client?

A nurse is talking with a client who reports constipation. When the nurse discusses dietary changes that can help prevent constipation, which of the following foods should the nurse recommend?

A nurse is caring fr a client who has hd diarrhea for the past 4 days. When assessing the client, the nurse should expect which of the following findings? (SATA)

A nurse is preparing to administer a cleansing enema to an adult client in preparation for a diagnostic procedure. Which of the following are appropriate steps for the nurse to take? (SATA)

While a nurse is administering a cleansing enema, the client reports abdominal cramping. Which of the following is the appropriate intervention?

A nurse is preparing info for change-of-shift report. Which of the following info should the nurse include in the report?

A nurse enters a client's room and finds him sitting in his chair. He sates, "I fell in the shower, but I got myself back up and into my char." How should the nurse document this in the client's chart?

A nursing instructor is reviewing documentation with a group of nursing students. Which of the following legal guidelines should they follow when documenting in a client's record? (SATA)

A nurse is receiving a provider's prescription by telephone for morphine for a client who is reporting moderate to severe pain. Which of the following nursing actions are appropriate? (SATA)

A nurse is delivering an enteral feeding to a client who has an NG tube in place for intermitttent feedings. When the nurse pours water into the syringe after the formula drains from the syringe, the client asks the nurse why the water is necessary. Which of the following is an appropriate response by the nurse?

A nurse is preparing to instill an enteral feeding to a client who has an NG tube in place. Which f the following is the nurse's highest assessment priority before performing this procedure?

A nurse is caring for a client who is receiving continuous enteral feedings. Which of the following nursing interventions is the highest priority when the nurse suspects aspiration of the feeding?

A nurse is caring for a client in a long-term care facility who is receiving enteral feedings via NG tube feeding? (SATA)

A nurse is preparing to insert an NG tube for a client who requires gastric decompression. Which of the following actions should the nurse perform before beginning the procedure? (SATA)