Fundamentals 2019
1. A nurse is documenting client care. Which of the following abbreviation should the nurse use?
a. "SS" for sliding scale
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b. "OJ" for orange juice
c. "BRP" for bathroom privileges
d. "SQ” for subcutaneous
2. A nurse is caring for a client who reports pain level of 5 on a scale from 0 to 10 the client informs the nurse that pain medications are not an option for managing pain. Which of the following is an appropriate response by the nurse?
a. Why do you think pain medication is not going to help you?
b. You may take any herbal remedies to bring from home
c. I'm sure it will work if you just give it a chance
d. would you like me to give you a back massage?
3. A nurse is caring for a client following a laparoscopic cholecystectomy. The client has a prescription for Ondasteron 4 mg IV bolus every 6 hours PRN for nausea and vomiting. Identify the sequence of steps the nurse should follow to administer the medication. Move the steps in the Box on the right, placing them in the order of performance. Use all steps.
1. Perform hand hygiene.
2. Select the injection port of the IV tubing closest to the client.
3. Aspirate for a blood return.
4. Cleanse the injection port with an antiseptic swab.
5. Inject the medication.
4. A charge nurse in a long-term care facility is preparing an educational program about Delerium for newly hired nurses. Which of the following statements should the nurse plan to include?
a. Delirium has an Abrupt onset
b. delirium does not affect the client's perception of her environment
c. delirium has a slow progression
d. delirium does not affect a client's sleep cycle
5. A nurse is caring for a client who has dysphagia and is receiving oral medications. Which of the following actions should the nurse take?
a. Administer the clients medication one at a time.
b. Assist a client into a semi Fowler's position
c. encourage the client to use a straw to take the medications
d. give the clients medications between meals
6. A nurse is preparing a client who has terminal cancer for discharge. Which of the following question should the nurse ask when assessing the client's psychological history?
a. What medications are you currently taking?
b. Are you experiencing any pain?
c. What techniques do you use to cope with stress?
d. Have any of your relatives been diagnosed with cancer?
7. A nurse is conducting a health assessment for a client who takes herbal supplements. Which of the following statements by the client indicates an understanding of the use of supplements?
a. I take action echinacea to control my cholesterol
b. I use garlic for my menopausal symptoms
c. I take ginkgo biloba for a headache
d. I use ginger when I get car sick (this)
8. A nurse is discussing incident report with a group of newly licensed nurses. The nurse should include that which of the following situations requires the completion of an incident report?
a. A nurse transfused a unit of packed red blood cells in 2 hours
b. an oncoming nurse arrived to work late
c. a client with your consent for a procedure
d. a client is prescribed Laboratory Testing was not obtained
9. A nurse is teaching a client about repositioning into the Sims position. Which of the following information should the nurse include in the teaching?
a. Your arms will be placed at your sides
b. you will be placed on your stomach
c. you will be turn to one side with your legs fixed
d. the head of your bed will be elevated to a 45 degree angle
10. A nurse is communicating with a client who has Aphasia following a stroke. The client is having difficulty choosing the correct words during their conversation. Which of the following responses should the nurse make??
a. Take as much time as you need to communicate
b. why do you think you are having trouble speaking?
c. I can ask your family member or friend to complete your thoughts
d. I will request an interpreter to help you communicate
11. A nurse receives a telephone prescription from a provider for a client who is experiencing pain. Which of the following responses should the nurse make?
a. Let me provide you with a client's medical record number for identification
b. will you please spell the name of that medication for me?
c. I will sign my name now and leave a space for you to sign your name
d. let me clarify that you want the medication given qid, correct?
12. A nurse is collecting a sputum specimen for culture from a client who has respiratory infection. Which of the following actions should the nurse take?
a. Collect 1 ml of sputum
b. collect the specimen in the evening
c. wear sterile gloves when collecting the specimen
d. offer the client oral hygiene after the collection
13. A nurse is teaching a client who has diabetes mellitus about mixing regular insulin and NPH insulin. Which of the following statements by the client indicates an understanding of the teaching?
a. I should wait three minutes after mixing the insulin to inject it
b. I should roll the vial of NPH insulin between my hands before drawing it up
c. I should inject air into the vial of regular insulin first
d. I should draw up the NPH insulin before the regular insulin
14. A nurse is planning care for a client who reports having latex allergy. Which of the following interventions should the nurse include in the plan?
a. Apply adhesive tape when securing an IV insertion site
b. Apply powdered gloves when providing care to the client
c. cover the blood pressure cuff with stockinette
d. use plastic syringes for medication administration
15. The nurse obtains a prescription for wrist restraints for a client who is trying to pull out his NG tube. Which of the following actions should the nurse take?
a. Apply the restraints to allow as little movement as possible
b. Allow room for two fingers to fit between the client's skin and restraints
c. attached the restraint securely to the side rails of the client's bed
d. remove the restraints every 4 hours
16. A nurse is teaching a client about fire safety at home. Which of the following information should the nurse include in the teaching?
a. Cover the nose and mouth with a damp cloth before exiting a smoke-filled area
b. change the batteries in a smoke detector every two years
c. Place multiple smoke detectors in the same area of the home
d. open a window to let smoke out before leaving the home
17. A nurse is caring for a client who has terminal illness. The client states “ I do not know which treatments I want to continue and which treatments I should avoid” which of the following responses should the nurse make?
a. Why are you feeling indecisive about these treatment options?
b. Would you like to talk about the different treatment options?
c. I would recommend accepting all of the treatment options offered
d. you should discuss your treatment options with your family
18. A nurse is caring for a client who has pneumonia. The nurse should recognize that which of the following should be discarded in a biohazard bag?
a. A calibrated toilet insert filled with urine
b. a bedpan containing diarrhea from a client who is receiving antibiotics
c. a disposable tissue containing exportarated sputum
d. an emesis basin filled with blood from severe coughing
19. A nurse is caring for a client who is receiving enteral feeding via NG tube. Which of the following actions should the nurse take prior to administering the formula?
a. Encourage the client to breathe deeply and cough
b. encourage the client to take sips of water
c. Flush the tube with sterile 0.9% sodium chloride irrigation
d. check for gastric residual volume
20. Nurse is teaching a client about the us [Show Less]