Fundamentals of Nursing
A nurse is performing an admission assessment for an older adult. After gathering the data, which of the following actions is a priority for the nurse
Orient the client to his room
Conduct a client care confrence
Review the client's medical orders
Develop a plan of care
A nurse is admitting a client who has acute cholecystitis to a med-sug unit. Which of the following actions are essential steps to the admission procedure? (SATA)
Explain the roles of other care devlivery staff
Begin discharge planning
Provide info about advance directives
Document the client's wishes about organ donation
Introduce the client to his roomate
A nurse is transferring a client from an acute-care hospital to a rehab. Which of the following info about the client should the nurse include in the transfer report? (SATA)
Alert and oriented
Refuses to eat spinach
Has a shellfish allergy
Requests morphine every 4 hr
Misses the two cars he has at home
A nurse is preparing the discharge summary for a client who has had knee arthroplasty and is going home. Which of the following info about the client should the nurse include in the discharge summary? (SATA)
Advance directives
Where to go for follow-up care
Instructions for diet and meds
Most recent vital signs data
Contact info for the home health care agency
As part of the admission process, a nurse at a long-term care facility is gathering nutrition history. Which of the following components is the priority for the nurse to determine?
Body mass index
Usual times for meals and snacks
Favorite foods
Any difficulty swallowing
When entering a client's room to change a surgical dressing, a nurse notes that the client is coughing and sneezing. When preparing the sterile field, it is important that the nurse
Keep the sterile field at least 6ft away from the client's bedside
Instruct the client to refrain from coughing and sneezing during the dressing change
Place a mask on the client to limit the spread of microorganisms into the surgical wound
Keep a box of facial tissues nearby for the client to use during the dressing change
A nurse is wearing sterile gloves in preparation for performing a sterile procedure. Which of the following objects may the nurse touch without breaching sterile technique? (SATA)
A bottle containing a sterile solution
The edge of the sterile drape at the base of the field
The inner wrapping of an item on the sterile field
An irrigation syringe on the sterile field
One gloved hand with the other gloved hand
A nurse has removed a sterile pack from its outside cover and placed it on a clean work surface in preparation for an invasive procedure. Which of the following flaps should the nurse unfold first?
The flap closest to the body
The right side flap
The left side flap
The flap farthest from the body
A nurse is reviewing hand hygiene techniques with a group of assistive personnel. Which of the following instructions should the nurse include when discussing handwashing? (SATA)
Apply 3 to 5 mL of liquid soap to dry hands
Wash the hands with soap and water for at least 15 seconds
Rinse the hands with hot water
Use a clean paper towel to turn off hand faucets
Allow the hands to air dry after washing
A nurse has prepared a sterile field for assisting a provider with chest tube insertion. Which hof the following events should the nurse recognize as contaminating the sterile field? (SATA)
The provider drops a sterile instrument onto the near side of the sterile field
The nurse moistens a cotton ball with normal saline and places it on the sterile field
The procedure is delayed 1hr because the provider receives an emergency call
The nurse turns to speak to someone who enters though the door behind the nurse
The client's hand brushes against the outer edge of the sterile field
A nurse is caring for a client diagnosed with severe acute respiratory syndrome. The nurse is aware that health care professionals are required to report communicable and infectious diseases. Which of the following illustrate the rationale for reporting? (SATA)
Planning and evaluating control and prevention strategies
Determining public health priorities
Ensuring proper medical treatment
Identifying endemic disease
Monitoring for common-source outbreaks
A nurse is contributing to tplan of care 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)
Place the client in a room that has negative air pressure of at least six exchanges per hour.
Wear a mask when providing care within 3ft of the client
Place a surgical mask on the client if transportation to another department is unawoidabl
Use sterile gloves when handling soiled linens
Wear a gown when preforming care that may result in contamination from secretions
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?
Allergic reaction
Ringworm
Systemic lupus erythematosus
Herpes zoster
A nurse 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?
Prodromal
Incubation
Convalescence
Illness
A nurse educator is reviewing with a nearby hired nurse the difference in clinical manifestations of a localized versus a systematic infection. The nurse indicates understanding when she states that the which of the following are clinical manifestations of a systemic infection? (SATA)
Malaise
Edema
Pain or tenderness
Increase in pulse and respiratory rate
Fever
A nurse is caring for a client who was just admitted to the unit after falling at a nursing home. This client is oriented to person, place, and time and can follow directions. Which of the following actions by the nurse are appropriate to decrease the risk of a fall? (SATA)
Place a belt restraint on the client when he is sitting on the bedside commode
Keep the bed in low position with full side rails up
Ensure that the client's call light is within reach
Provide the client with nonskid footwear
Complete a fall-risk assessment
A nurse manager is reviewing care of a client who has had a seizure with nurses on the unit. Which of the following statements by a nurse requires further instruction?
"I will place the client on his side"
"I will go to the nurses' station for assistance"
"I will administer medications as prescribed"
"I will be prepared to insert an airway
A nurse observes smoke coming from under the door of the staff lounge. Which of the following is the priority action by the nurse?
Extinguish the fire
Pull the fire alarm
Evacuate the clients
Close all open doors on the unit
A charge nurse is designating room assignments fro clients who will be admitted to the unit. Based on the nurse's knowledge of fall prevention, which of the following clients should be assigned to the room closest ti the nurses' station?
A 43-year-old client who is postoperative following a laparoscopic cholecystectomy
A 6-year-old client being admitted for telemetry to rule out a myocardial infarction
A 50-year-old client who is postoperative following an open reduction internal fixation of the ankle
A 79-year-old client who is postoperative following a below-the-knee amputation
A nurse is caring for a newly admitted client who has a documented history of falls. Which of the following is the priority action by the nurse?
Complete a fall-risk assessment
Complete a physical assessment
Educate the client and family on fall risks
Survey the client's belongings
A nurse is providing discharge instructions to a client who has a prescription for the use of oxygen in his hoe. Which of the following should the nurse teach the client about using oxygen safely in his home? (SATA)
FAmily members who smoke must be at least 10 ft away from the client when oxygen is in use
Nail polish should not be used near a client who is receiving oxygen
A "No Smoking" sign should be place on the front door
Cotton bedding and clothing should be replaced with items made from wool
A fire extinguisher should be readily available in the home
A nurse educator is conducting a parenting class for new parents. Which of the following statements made by a participant indicates a need for further clarification and instructions?
"I will begin swimming lessons as soon as my baby can close her mouth under water"
"Once my baby can sit up, he should be safe in the bathtub"
"I will test the temp of the water before placing my baby in the bath
"Once my infant starts to push up, I will remove the mobile from over the bed"
A home health nurse is discussing the dangers of carbon monoxide poisoning with a client. Which of the following info should the nurse include in her counseling?
Carbon monoxide has a distinct odor
Water heaters should be inspected every 5 years
The lungs are damaged from carbon monoxide
Carbon monoxide binds with hemoglobin in the body
A nurse educator is presenting a module on basic first aid for newly licensed home health nurses. The nurse educator evaluates the teaching as effective when the newly licensed nurse states the client who has heat stroke will have which of the following?
Hypotension
Bradycardia
Clammy skin
Bradypnea
A home health nurse is discussing the dangers of food poisoning with a client. Which of the following info should the nurse include in her counseling? (SATA)
Most food poisoning is caused by a virus
Immunocompromised individuals are at risk for complications from food poisoning
Clients who are especially at risk are instructed to eat or drink only pasteurized milk, yogurt, cheese, or other dairy products
Healthy individuals usually recover from illness in a few weeks
Handling raw abd fresh food separately to avoid cross contamination may prevent food poisioning
A nurse is caring for a client receiving enteral tube feedings due to dysphagia. Which of the following bed positions is appropriate for safe care of his client?
Supine
Semi-Fowler's
Semi-prone
Trendelenburg
A nurse is caring for a client who is sitting in a chair and asks to return to bed. Which of the following is the priority action for the nurse to take at this time?
Obtain a walker for the client to use to transfer back to bed
Call for additional personnel to assist with the transfer
Use a transfer belt and assist the client to bed
Assess the client's ability to help with the transfer
A nurse is completing discharge teaching to a client who has COPD. The client verbalizes understanding of the orthopneic position when he states, "When I have difficulty breathing at night, I wil
Lie on my back with my head and shoulders elevated on a pillow
Lie flat on my stomach with my head to one side
Sit on the side of my bed and rest my arms over pillows on top of my raised bedside table
Lie on my side with my weight on my hips and shoulder with my arms flexed in front of me
A nurse manager is reviewing guidelines to prevent injury with staff nurses. Which of the following should the nurse manager include in the teaching? (SATA)
Request assistance when repositioning a client
Avoid twisting a spine or bending at the waist
Keep the knees slightly lower than the hips when sitting for long periods of time
Use smooth movements when lifting and moving clients
Take a break from repetitive movements every 2 to 3 hr to flex and stretch joints and muscles
A nurse educator is teaching a module on proper body mechanics during employee orientation. Which of the following statements by a newly hired nurse indicates the need for further teaching?
"My line of gravity should fall outside my base of support"
"The lower y center of gravity, the more stability I have"
"To broaden my base of support, I should spread my feet apart"
"When I lift an object, I should hold it as close to my body as possible"
A nurse is caring for multiple clients during a mass casualty event. Which of the following clients is the highest priority?
A client who received crush injuries to the chest and abdomen and is expected to die
A client who has a 4-in laceration to the head
A client who has partial-thickness and full-thickness burns to his face, neck, and chest
A client who has a fractured fibula and tibia
A nurse on a med-surg unit is informed that a mass casualty event occurred in the community and that it is necessary to discharge clients to make beds available for injury victims. Which of the following clients can be safely discharged? (SATA)
A client who is dehydrated and receiving IV fluid and electrolytes
A client who has a nasogastric tube to treat a small bowel obstrucion
A client who is scheduled for a transurethral resection of the prostate (TURP)
A client who is 24 hr postoperative following a mastectomy
A client who is scheduled for an appendectomy
A nurse educator is discussing the facility protocol in the event of a tornado with the staff. Which of the following should the nurse include in the instructions? (SATA)
Open doors to client rooms
Place blankets over clients who are confined to beds
Move beds away from he windows
Draw shades and close drapes
Relocate ambulatory clients in the hallways back into their room
An occupational health nurse is caring for an employee who was exposed to an unknown dry chemical, resulting in a chemical burn. Which of the following interventions should the nurse include in the plan of care?
Irrigate the affected area with running water
Wash the affected area with antibacterial soap
Brush the chemical off the skin and clothing
Apply a neutralizing agent
A security officer is reviewing actions to take in the event of a bomb threat by phone to a group of nurses. Which of the following statements by a nurse indicates understanding of proper procedure?
"I will get the caller off the phone as soon as possible so I can alert the staff"
"I will use overhead paging to alert the entire facility"
"I will not ask any questions and just let the caller talk"
"I will listen for background noises"
A nurse is caring for a 19-year-old client who is sexually active and has come to the college health client for the first time for a checkup. Which of the following interventions should the nurse perform first to determine the client's need for health promotion and disease prevention?
Measure the client's vital signs
Encourage HIV screening
Determine the client's risk factors
Instruct the client to use condoms
A nurse in a health clinic is caring for a 21-year-old client who reports a sore throat. The client tells the nurse that he has not seen a doctor since high school. Which of the following health screenings should the nurse expect the provider to perform for his client?
Testicular examination
Blood glucose
Fecal occult blood
Prostate -specific antigen
A nurse at a provider's office is talking with a 45-year-old client who has no specific family history of cancer or diabetes mellitus about planning her routine screenings. Which of the following client statements indicates that the client understands how to proceed?
"So I don't need the colon cancer procedure for another 2 or 3 years"
"For now, I should continue to have a mammogram each year"
"Because the doctor just did a Pap smear, I'll come back next year for another one"
"I had my blood glucose test last year, so I won't need it again till next year"
A nurse is talking with a client who recent;y attended a cholesterol screening event and a heart-healthy nutrition presentation at a neighborhood center. His total cholesterol result from the screening was 248 mg/dL, so he saw his provider and received a med prescription to improve his cholesterol level. The client was later hospitalized for severe chest pain, and subsequently enrolled in a cardiac rehab program. Which of the following activities of this client is an example of primary prevention?
Cholesterol screening
Nutrition presentation
Medication therapy
Cardiac rehab
A nurse in a clinic is caring who has multiple risk factors for cardiovascular disease. When planning health promotion and disease prevention strategies for this client, which of the following interventions should the nurse include? (SATA)
Help the client see the benefits of her actions
Identify the client's support systems
Suggest and recommend community resources
Device and set goals for the client
Teach stress management strategies
When a nurse is observing a client drawing up and mixing insulin injections, which of the following best demonstrates that psychomotor learning has taken place?
The client is able to discuss the appropriate technique
The client is able to demonstrate the appropriate technique
The client states that he understands
The client is able to write the steps on a piece of paper
A nurse in a provider's office is collecting data from the mother of a 1-year-old child. The nurse states that her child is old enough for toilet training. Following an educational session by the nurse, the client now states that her earlier ideas have changed. She is now willing to postpone toilet training until the child is older. Learning has occurred in which of the following domains?
Cognitive
Affective
Kinesthetic
Psychomotor
A nurse is providing preoperative teaching for a client who is scheduled for a mastectomy the next day. Which of the following client statements indicates that the client is ready to learn?
"I don't want my spouse to see my incision"
"Will you be able to give me pain medicine after the surgery?"
"Can you tell me about how long the surgery will take?"
"My roommate listens to everything I say"
A nurse is preparing an instructional session about managing stress incontinence for an older adult. Which of the following actions should the nurse take first when meeting with the client?
Encourage the client to participate actively in learning
Select instructional materials appropriate for the older adult
Identify goals the nurse and the client agree are reasonable
Determine what the client knows about stress incontinence
A nurse is evaluating how well a client learned the info presented in an instructional session about following a heart-healthy diet. The client states that she understands what to do now. Which of the following actions by the nurse should assist the nurse in evaluating the client's learning?
Encourage the client to ask questions
Ask the client to explain how to select or prepare meals
Encourage the client to fill out an evaluation form
Ask the client if she has resources for further instruction on this topic
A nurse is introducing herself to a client as the first step of a comprehensive physical examination. Which of the following strategies should the nurse use with this client? (SATA)
Address the client with the appropriate title and her last name
Use a mix of open- and closed-ended questions
Reduce environmental noise
Have the client complete a printed history form
Perform the general survey before examination
A nurse in a provider's office is documenting his findings following an assessment he performed for a client new to the practice. Which of the following parameters should he include as part of the general survey? (SATA)
Posture
Skin lesions
Speech
Allergies
Immunization status
A nurse is collecting data for a client's comprehensive physical examination. After the nurse inspects the client's abdomen, which of the following skills of the physical examination process should she perform next?
Olfacation
Auscultation
Palpation
Percussion
A nurse is performing a comprehensive physical examination for an older adult. Which of the following interventions should the nurse use in consideratation of the client's age? (SATA)
Perform the assessments in one continuous session
Plan to allow plenty of time for position changes
Make sure the client has any essential sensory aids in place
Tell the client to take her time answering questions
Invite the client to use the bathroom before beginning the examination
A nurse in a family practice clinic is performing a physical examination of an adult client. Which part of her hands should she use during palpation for optimal assessment of the client's skin temp?
Palmar surface
Fingertips
Dorsal surface
Base of fingers
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 respiratory rate of 22/min. He is restless and his skin is warm. Which of the following are appropriate nursing interventions for this client? (SATA)
Obtain culture specimens before initiating antimicrobials
Restrict the client's oral fluid intake
Encourage the client to limit activity and rest
Allow the client to shiver to dispel excess heat
Assist the client with oral hygiene frequently
A nurse is instructing an AP in caring for 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?
"Do not measure the client's temp rectally"
"Count the client;s radial pulse for 30 sec and multiply it by 2"
"Do not let the client know you are counting her respirations"
"Let the client rest for 5 min before you measure her blood pressure"
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)
Place the client in semi-Fowler's position
Have the client rest a arm across the abdomen
Observe one full respiratory cycle before counting rate
Count the rate for 1 min if it is regular
Count and report any sighs the client demonstrates
A nurse who is admitting a client who has a fractured femur obtains a blood pressure reading 140/94. The client denies any history of hypertension. Which of the following actions should the nurse take next?
Request a prescription for an antihypertensive medication
Ask the client if she is having pain
Request a prescription for an anti-anxiety medication
Return in 30 min to recheck the client's BP
A nurse in a provider's office is preparing to test a client's cranial nerve function. Which of the following directions should she include when testing cranial nerve V? (SATA)
"Close you eyes"
"Tell me what you can taste"
"Clench your teeth"
"Raise your eyebrows
"Tell me when you feel a touch"
A client asks the nurse what her Snellen eye test results mean. Her visual acuity is 20/30. Which of the following responses is appropriate?
"Your eyes see at 20 ft what visually unimpaired eyes see at 30 ft"
"Your right eye can see the chart clearly at 20 ft, and your left eye can see the chart clearly at 30 ft"
"Your eyes see at 30 ft what visually unimpaired eyes see at 20 ft"
"Your left eye can see the chart clearly at 20 ft, and your right eye can see the chart clearly at 30 ft"
A nurse is assessing a client's thyroid gland as part of a comprehensive physical examination. Which of the following findings should the nurse expect? (SATA)
Palpating the thyroid in the lower half of the neck
Visualizing the thyroid on inspection of the neck
Hearing a bruit when auscultating the thyroid
Feeling the thyroid ascend as the client swallows
Finding symmetric extension of the trachea on both sides of the midline
A nurse is assessing an adult client's internal ear canals with an otoscope as part of a head and neck examination. Which of the following actions are appropriate? (SATA)
Pull the auricle down and back
Insert the speculum slightly down and forward
Insert the speculum 2 to 2.5 cm (0.8 to 1in)
Make sure the speculum does not touch the ear canal
Use the light to visualize the tympanic membrane in a cone shape
A nurse is performing a head and neck examination for an older adult client. Which of the following age-related findings should the nurse expect? (SATA)
Reddened gums
Lowered vocal pitch
Tooth loss
Glare intolerance
Thickened eardrums
A nurse in a provider's office is preparing to perform a breast examination for an older adult who is postmenopausal. Which of the following findings should the nurse expect? (SATA)
Smaller nipples
Less adipose tissue
Nipple discharge
More pendulous
Nipple inversion
A nurse in a provider's office is preparing to auscultate and percuss a client's thorax as part of a comprehensive physical examination. Which of the following findings should the nurse expect? (SATA)
Rhonchi
Crackles
Resonance
Tactile fremitus
Bronchovesicular sounds
During an abdominal examination, a nurse in a provider's office determines that a client has abdominal distention. The protrusion is at midline, the skin over the area is taut, and the nurse notes no involvement of the flanks. Which of the following possible causes of distention should he nurse suspect?
Fat
Fluid
Flatus
Hernias
During a cardiovascular examination, a nurse in a provider's office places the diaphragm of the stethoscope on the left midclavicular line at the fifth intercostal space. Which of the following heart sounds is the nurse attempting to auscultate? (SATA)
Ventricuar gallop
Closure of the mitral valve
Closure of the pulmonic valve
Closure of the tricuspid valve
Murmur
A nurse in a provider's office is preparing to auscultate and percuss a client's abdomen as part of a comprehensive physical examination. Which of the following findings should the nurse expect? (SATA)
Tympany
High-pitched clicks
Borborygmi
Friction rubs
Bruits
A nurse in a provider's office is preparing to assess a client's skin as part of a comprehensive physical examination. Which of the following findings should the nurse expect? (SATA)
Capillary refill in 2 sec
1+ pitting edema in both feet
Pale nail beds in both hands
Thick skin on the soles of the feet
Numerous light brown macules on the face
A nurse's assessment of an older adult client identifies significant tenting of the skin over his forearm. Which of the following can explain this finding? (SATA)
Thin, parchment-like skin
Loss of adiopse tissue
Dehydration
Diminished skin elasticity
Excessive dryness and wrinkling
A nurse is caring for a client who is postoperative following knee surgery. Which of the following should the nurse examine to assess the client's peripheral vascular system? (SATA)
Range of motion
Skin color
Edema
Skin lesions
Skin temp
A nurse is reviewing the various types of lesions nursing students might encounter when performing integumentary assessments for their clients. Which of the following lesions should the nursing students recognize as vesicles? (SATA)
Acne
Warts
Psoriasis
Herpes simplex
Varicella
A nurse is instructing a group of nursing students in the priorities of care in performing an integumentary assessment for their clients. Which of the following findings should the students recognize as requiring immediate intervention?
Pallor
Cyanosis
Jaundice
Erythema
A nurse in a provider's office is preparing to assess a young adult male client's musculoskeletal system as part of a comprehensive physical examination. Which of the following findings should the nurse expect? (SATA)
A concave thoracic spine posteriorly
An exaggerated lumbar curvature
A concave lumbar spine posteriorly
Ann exaggerated thoracic curvature
Muscles slightly larger on his dominant side
A nurse is evaluating a client's neurosensory system. To evaluate stereognosis, she should ask the client to close his eyes and identify which of the following items?
A word she whispers 30 cm from his ear
A number she traces on the palm of his hand
The vibration of a tuning fork sh places on his foot
A familiar object she places in his hand
A nurse is assessing a client who reports pain when the nurse evaluates the internal rotation of her right shoulder. Which of the following activities is this problem likely to affect?
Mopping the floors
Brushing the back of her hair
Fastening her bra behind her back
Reaching into a cabinet above her sink
{"name":"Fundamentals of Nursing", "url":"https://www.quiz-maker.com/QPREVIEW","txt":"A nurse is performing an admission assessment for an older adult. After gathering the data, which of the following actions is a priority for the nurse, A nurse is admitting a client who has acute cholecystitis to a med-sug unit. Which of the following actions are essential steps to the admission procedure? (SATA), A nurse is transferring a client from an acute-care hospital to a rehab. Which of the following info about the client should the nurse include in the transfer report? (SATA)","img":"https://www.quiz-maker.com/3012/images/ogquiz.png"}
More Quizzes
100
Gay Quiz!
520
Pre-Test Evaluation for "Investigation Crime Scene: Fingerprints"
320
Bible contest
16821
What do you think is the most interesting paper(s) today? Let's vote and let people know!
100
Flavor of Love S1 Quiz
105357
Quiz 2
211047
UA & FA Picture quiz
35180
Hidrólisis acetato de amonio
210
Relais Colis Version 1
940
Discover Your Leadership Style
11639
3.A
11615