PN Fundamentals Online Practice 2020 B With rationales for correct answer.

A nurse is planning to administer medication to a client who has a Clostridium difficile infection. Which of the following actions should the nurse plan to take to prevent the transmission of this infection to others? A. Clean hands with an alcohol-based hand rub immediately after removing gloves. B. Remove the cover gown in the client's room after providing care. C. Place the client in a room with negative-pressure airflow D. Wear a mask when administering oral medications to the client. - ANSWER B. Remove the cover gown in the client's room after providing care. (The nurse should initiate contact precautions for clients who have a C. difficile infection. Contact precautions include the removal of the cover gown and other personal protective equipment inside the client's room to prevent the spread of infection). A nurse is reinforcing teaching with a client who is scheduled for a bladder scan. Which of the following instructions should the nurse include in the teaching? A. "You will need to sign a consent form before we begin the procedure." B. "I will place a gel pad directly above your pubic area before I place the probe." C. "You will need to hold your urine for 1 hour prior to the procedure." D. "You will receive a contrast dye through an IV catheter prior to the scan." - ANSWER B. "I will place a gel pad directly above your pubic area before I place the probe." (The nurse should use a gel pad, which promotes ultrasound transmission and accurate measurement. The correct placement of the ultrasound device is just above the symphysis pubis.) A nurse is checking a client for a pulse deficit after detecting an irregular heart rate. Which of the following actions should the nurse take? A. Count the client's radial and apical pulses simultaneously with another nurse. B. Calculate the client's pulse for 30 seconds and multiply by 2. C. Assist the client to a side-lying position. D. Auscultate the area of the client's chest over the Erb's point. - ANSWER A. Count the client's radial and apical pulses simultaneously with another nurse. (The nurse should have another nurse count the radial pulse as they count the apical pulse. A pulse deficit occurs when there are differences between the radial and apical pulse rates.) A nurse is preparing to obtain a clients vital signs. Which of the following actions should the nurse take when washing their hands? A. Rinse their forearms with running water before applying soap. B. Hold their hands above elbow level while washing and rinsing. C. Generate a lather by rubbing their hands together vigorously for 5 seconds. D. Turn off the faucet with a clean paper towel after drying hands. - ANSWER D. Turn off the faucet with a clean paper towel after drying hands. (If the nurse's hands are wet or the paper towel is wet when they turn off the faucet, they increase the risk of transferring micro-organisms from the faucet back to their hands.) A nurse is preparing to perform a wound irrigation for a client who has a stage 3 pressure injury. Which of the following supplies should the nurse plan to use? A. A piston syringe. B. Barrier ointment. C. Chilled irrigation solution. D. Sterile cotton balls. - ANSWER A. A piston syringe (The nurse should use an irrigation or piston syringe with an angiocatheter attached to irrigate wounds because it provides a gentle flow of solution to flush exudate and debris from the wound. A nurse is caring for a client who has dyspnea caused by a respiratory infection. The nurse should assist the client into which of the following positions. A. Orthopneic. B. Dorsal recumbent. C. Sims' D. Prone. - ANSWER A. Orthopneic. (The nurse should assist the client into the orthopedic position by having the client sit upright either in bed or in a chair and lean forward. This position allows maximal chest expansion and facilitates breathing). A nurse in reinforcing teaching about carbohydrate counting with a client who has a new diagnosis of diabetes mellitus. Which of the following actions should the nurse take first? A. Use pictures of different food groups to help the client plan a daily menu. B. Ask the client what they already know about meal planning. C. Give the client a brochure with sample menus for all meals. D. Involve the family in the discussion of the client's meal plan. - ANSWER B. Ask the client what they already know about meal planning. (The first action the nurse should take using the nursing process is to collect data to determine the client's current level of knowledge. Then, the nurse can plan education to meet the client's needs). A nurse is caring for a client who has a new prescription for oxygen at 7 L/min via simple face mask. Which of the following actions should the nurse take to ensure client safety? A. Keep the side holes of the mask closed. B. Ensure the reservoir bag is inflated on expiration. C. Apply petroleum jelly to the client's nostrils. D. Attach a humidifier to the base of the flow meter. - ANSWER D. Attach a humidifier to the base of the flow meter. (The nurse should attach a humidifier at the base of the flow meter to moisten the air for the client. This action will prevent dying mucous membranes when the client is receiving oxygen at a rate greater than 4 L/min). A nurse is contributing to the plan of care for a client who practices Islam. Which of the following questions should the nurse ask the client to clarify the client's religious preferences? A. "Do you receive Holy Communion?" B. "Do you follow a kosher diet?" C. "Do you consume pork products?" D. "Do you oppose receiving a blood transfusion if it is needed?" - ANSWER C. "Do you consume pork products?" (Some clients who practice Islam do not consume pork or alcohol). A nurse is caring for a client who has limited mobility. Which of the following actions should the nurse take to maintain the client's skin integrity? A. Use warm water when bathing the client. B. Place a donut shaped cushion in the client's chair. C. Massage reddened areas over bony prominences. D. Maintain the client in high-Fowler's position. - ANSWER A. Use warm water when bathing the client. (The nurse should use warm water to bathe the client because hot water can dry and damage the skin). A nurse is caring for four clients. For which of the following clients should the nurse use the therapeutic communication technique of silence? A. A client who plans to leave the facility against medical advice. B. A client who informs the nurse that they have made their funeral arrangements. C. A client who tells the nurse that the night shift nurse did not bring their medication. D. A client who has just experienced the death of their child. - ANSWER D. A client who has just experienced the death of their child. (Silence is a therapeutic communication technique to use when a client is grieving. It demonstrates caring and patience and allows the client to speak when they are ready to do so). A nurse is caring for a group of clients in a long-term care facility. Which of the following actions should the nurse take to prevent health care-associated infections for these clients? (Select all that apply) -Place immunocompromised clients in the same room. -Wash hands after removing gloves. -Use antimicrobial hand gel after refilling a client's water pitcher -Clean the stethoscope with an antimicrobial wipe after obtaining vital signs. -Administer a prophylactic dose of antibiotics prior to discharge. - ANSWER -Wash hands after removing gloves. (The nurse should perform hand hygiene after removing gloves to prevent the transmission of micro-organisms from one setting or client to another). -Use antimicrobial hand gel after refilling a client's water pitcher (The nurse should perform hand hygiene after touching a client's supplies to prevent the transmission of micro-organisms). -Clean the stethoscope with an antimicrobial wipe after obtaining vital signs. (The nurse should wipe all equipment used for multiple clients with an antimicrobial wipe to prevent the transmission of micro-organisms from one client to another). A nurse is caring for a client who has been vomiting and has diarrhea. Which of the following findings should the nurse identify as an indication of fluid volume deficit? A. BUN 18 mg/dL. B. A thready pulse. C. Hemoglobin 15 g/dL. D. Prominent neck veins. - ANSWER B. A thready pulse. ( A client who has fluid volume deficit will have thready peripheral pulses). A nurse is planning care for a group of clients. The nurse should expect to witness an informed consent for a client who will undergo which of the following procedures? A. Administration of an enema. B. Performance of a paracentesis. C. Insertion of an indwelling urinary catheter. D. Placement of an NG tube. - ANSWER B. Performance of a paracentesis. (The nurse should expect to witness the informed consent for a client prior to an invasive diagnostic procedure, such as a paracentesis). A nurse working in a community clinic is talking with an older client who states that their life has no purpose. The nurse should identify that the client is in which of the following stages of Erikson's Theory of Psychosocial Development? A. Ego integrity vs. despair B. Generativity vs. self-absorption C. Identity vs. role confusion D. Intimacy vs. isolation - ANSWER A. Ego integrity vs. despair (The nurse should identify that this client is experiencing the ego integrity vs. despair stage of Erikson's Theory of Psychosocial Development, which occurs in the older adult population. The nurse should assist the client to reflect on past accomplishments and find pleasure in life rather than focusing on health problems and limitations. Supporting the client's ego integrity will help the client cope with the challenges of aging). A nurse is caring for a client who has chronic pain. The nurse recommends that the client concentrate on a memory of a pleasurable experience. Which of the following complementary therapies is the nurse suggesting? A. Art therapy. B. Tai chi. C. Guided imagery. D. Biofeedback. - ANSWER C. Guided imagery. (Guided imagery is a technique that can produce physical changes in the body, such as decreasing pain levels, by concentrating on a visualization of a pleasurable memory). A nurse is reinforcing teaching about advance directives with a client who has end-stage renal disease. Which of the following client statements indicates an understanding of the teaching? A. "I know that I can change my advance directives if I need to in the future." B. "My health care surrogate will make my health care decisions as soon as I have signed the power of attorney." C. "My family can overrule the decisions made by my health care surrogate." D. "Advance directive from one state are valid in any other state." - ANSWER A. "I know that I can change my advance directives if I need to in the future." (The client can change their advance directives at their discretion). A nurse is providing care to four clients in an acute care setting. The nurse should identify that which of the following client statements presents an ethical dilemma? A. "I might file a lawsuit because of how my surgery went." B. "Please don't tell my doctor, but I am taking my partner's oxycodone." C. "Please don't get me out of bed this morning. It hurts too much." D. "I don't want to take my medicine. It makes me sick to my stomach." - ANSWER B. "Please don't tell my doctor, but I am taking my partner's oxycodone." ( This situation poses an ethical dilemma for the nurse because there is a conflict between what the