PN fundamentals A Exam Questions and Answers.

Nurse is reinforcing teaching with a client who has a prescription for a transcutaneous electrical nerve unit - ANSWER Nurse should instruct the client to place electrodes near or on the pain site to produce analgesia at the peripheral neuroreceptors Nurse is reinforcing teaching with a client who is receiving PCA. Which of the following statements by the clients indicates an understanding of the teaching ? - ANSWER I will not allow anyone to press the PCA button for me a Nurse is palpating the pulse located on top of a clients foot. Which of the following pulses should the nurse document that she is palpating ? - ANSWER Dorsalis Pedis A nurse is collecting data from a client who has an NG tube set to low intermittent suction. WHich of the following findings indicates hypomagnesemia? - ANSWER Positive Chvostek's sign A nurse is caring for a client who is alert and in a long term care facility. Which of the following actions should the nurse take to protect the clients privacy ? - ANSWER Ask the client before discussing his condition when family is present A nurse is collecting data from an older adult client. Which of the following findings should the nurse report to the provider ? - ANSWER The client reports urinary incontinence a nurse is reinforcing teaching with an older adult client who reports an inability to sleep which of the following information should the nurse include when teaching the client about aging and sleep ? - ANSWER Sleep pattern change with age A nurse is assisting with the admission of a client who has brough her medications to the facility. Which of the following actions should the nurse take ? - ANSWER Compare the medications the provider has prescribed with the clients meds a Nurse is reinforcing teaching with an older adult about oral hygiene . Which of the instructions should the nurse include ? - ANSWER Replace her toothbrush following an illness a nurse is assisting with a presentation to a group of older adults at a community center aboiut hypothermia and hyperthermia which of the following information should the nurse include about age related changes . - ANSWER Cirrculation becomes less efficient with age A nurse is caring for a client who has a clostridium difficile (C-Diff) infection. Which of the following solutions should the nurse use to perform hand hygiene while caring for this client? - ANSWER Mild soap A nurse is caring for a client who is postoperative and is experiencing cause and vomiting. The nurse should identify which of the following findings as indications that the client has fluid volume deficit? (Select all that apply) - ANSWER Decreased skin turgor, orthostatic hypotension, flat neck veins. A nurse writes client information on a piece of paper while receiving report. Which of the following actions should the nurse take to dispose of the paper? - ANSWER Shed the paper in a secure container. A nurse is reinforcing preoperative teaching with a client who does not speak the same language as the nurse. Which of the following actions should the nurse take? - ANSWER Provide handouts written in the client's primary language. A nurse is contributing to a plan of care for a client who has a new prescription for a wrist restraint. Which of the following actions should the nurse include in the plan? - ANSWER Pad bony prominence on the wrist A nurse is caring for a client who has recently undergone a total bilateral mastectomy. Which of the following statements by the client requires immediate action by the nurse? - ANSWER "When i look at myself in the mirror, I don't know if i can go on."` A Nurse is assisting witht he plan of care for a client who has a bacterial infection and a persistent oral temperature of 38.9 c 102 F Which of the folloiwing interventions should the nurse include in the plan of care to treat the fever ? - ANSWER Administer acetaminophen A nurse is contributing to the plan of care for a client who has a positive throat culture for strep. Which of the following interventions should the nurse recommend to be included in the plan of care? - ANSWER Ensure the client wears a surgical mask during transportation throughout the facility. A nurse is caring for a client who has a prescription for potassium supplement. The client tells the nurse that the pill is too large to swallow and refuses to take it. The nurse offers to break to pill into two smaller pieces. The nurse is demonstrating which of the following ethical principles? - ANSWER Beneficence A nurse is using Maslow's hierarchy of needs in assisting with discharge planning for a client. Which of the following activities should the nurse recommend as the priority for this client? - ANSWER Attend an exercise program. A nurse is reviewing the medical record of a client who has heart failure. The nurse should identify which of the following lab results as an indication that the client has fluid volume excess? - ANSWER BUN 8mg/dL A nurse is repositioning a client who has quadriplegia and is in the supine position. Which of the following actions should the nurse take to prevent client musculoskeletal injury? - ANSWER internally rotate the client's hips by using a trochanter roll. A nurse is caring for a female client who has urinary incontinence. Which of the following actions should the nurse take? - ANSWER Apply a moisture skin barrier to the client's perineal area. A nurse is caring for a client who has an indwelling urinary catheter. Which of the following actions should the nurse take to prevent urinary tract infection? - ANSWER Drain urine from the tubing before ambulation. A nurse is explaining ethics and values to a newly licensed nurse. The nurse should explain that allowing a client to make a decision about a treatment is an example of which of the following ethical principles? Accountability - ANSWER Autonomy A nurse is moving a client up in bed with the assistance of a second nurse. Which of the following actions should the nurse take? - ANSWER Place feet apart with the foot nearest the head of the client's bed in front of the other foot. A nurse is providing wound care for a group of clients. Which of the following wounds should the nurse identify as healing by secondary intention? - ANSWER A stage 3 pressure ulcer on the coccyx. A nurse is reinforcing teaching with a group of clients about carbon monoxide poisoning. Which of the following information should the nurse include in the teaching? - ANSWER Headache is a manifestation of carbon monoxide poisoning. A nurse is reinforcing teaching with a client about smoking cessation. Which of the following should the nurse identify as the first stage of health behavior change? - ANSWER Precontemplation. A nurse is caring for a client who has an NG tube and is receiving a continuous enteral feeding. Which of the following actions should the nurse take? - ANSWER Hold the feeding for two consecutive gastric residuals greater than 250 mL. A nurse has delegated various client care tasks to the assistive personnel (AP) on the care team. Which of the following actions by the AP should the nurse identify as correct? - ANSWER Donning a mask to measure the vital signs of a client who has pertussis. A nurse is reinforcing teaching about health promotion with a group of young adult clients. Which of the following information should the nurse include - ANSWER Young adults should receive a dental assessment every 6 months. A nurse is caring for a client who is disoriented and at risk for falls. Which of the following actions should the nurse plan to take? (Select all that apply) - ANSWER Ensure that the client is wearing nonskid slippers, reinforce teaching about how to use the call bell, and place the client in a room close to the nurse station. A nurse is reinforcing dietary teaching with a client who has chronic kidney disease and require s a low-potassium diet. Which of the following food choices by the client demonstrates an understanding of the teaching? - ANSWER 1 cup of applesauce A nurse is assisting with the admission of a client who has active TB. Which of the following actions should the nurse plan not take? - ANSWER Assign the client to a negative-pressure airflow room. A nurse is caring for a client who is receiving continuous NG tube feedings. The nurse listens to the client's bowel sounds. Which of the following actions should the nurse take? - ANSWER Decrease the rate of the feeding A nurse is reinforcing teaching with a client about the prevention of stress injuries. Which of the following instructions should the nurse include? - ANSWER "When lifting a heavy object, keep it close to your body." A nurse is reinforcing teaching with a client who has hearing loss about how to modify his home environment. Which of the following is a priority modification that the nurse should include? - ANSWER Flashing smoke alarm A client who has advanced cancer tells the nurse that he has a difficult time talking to anyone about the illness. Which of the following actions should the nurse take to encourage therapeutic communication? - ANSWER Let the client know that he is available and willing to listen. A nurse is preparing to administer an enteral feeding to a client who has an NG tube in place. Which of the following methods should the nurse use to verify correct placement of the NG tube? - ANSWER Check the PH of the gastric aspirate A nurse is caring for a client who is refusing medical treatment. Which of the following actions should the nurse take - ANSWER Document the clients refusal of treatment. A nurse is speaking with a client who has type 2 diabetes and a prescription for insulin. The client verbalizes anger about having to take insulin. Which of the following responses should the nurse make? - ANSWER "I see that you are angry. Let's sit down and talk." A nurse is reinforcing teaching about hospice care measures with the family of a client who is dying. Which of the following statements by a member of the client's family indicates an understanding of the teaching? - ANSWER "We will keep her room cool to help her breathe better." A nurse is preparing to remove a client's peripheral IV catheter. After performing hand hygiene and applying clean gloves, which of the following actions should the nurse take first? - ANSWER clamp the infusion tubing A nurse is assisting with the plan of care for four clients. Which of the following tasks should the nurse assign to an assistive personnel (AP)? - ANSWER "Assist a client to get out of bed after breathing treatment." A nurse is planning to perform wound irrigation for a client who has a large abdominal wound. Which of the following actions should the nurse plan to take? - ANSWER Administer an analgesic 30 mins before starting the procedure. A nurse in a long-term care facility is contributing to the plan of care of ra client who is at risk for pressure ulcers. Which of the following recommendations should the nurse include in the plan? - ANSWER Perform a thorough skin inspection each day. A charge nurse smells smoke, enters the visitor restroom, and sees flames in the trash can. What is the sequence of actions that the nurse should take? - ANSWER RACE- 1 Evacuate the clients from the area,2 Pull the lever to sound the alarm, 3 close the fire doors on the unit,4 Use the fire extinguisher A nurse is contributing to the plan of care for a client who has a prescription for elastic bandages to the lower extremities. Which of the following actions should the nurse recommend for the plan of care? - ANSWER Compare the clients pedal pulses bilaterally every 4 hr A nurse is caring for a client who has metastatic cancer and practices Catholicism. The client asks the nurse to discuss the afterlife with her. Which of the following statements by the nurse assists in meeting the client's spiritual needs? - ANSWER "Tell me what the afterlife means to you." A nurse is assisting with the plan of care for a client who has aphasia following a stroke. Which of the following interventions should the nurse use to assist the client with communication? - ANSWER Ask the client close-ended questions. A nurse is collecting data from a client who is menopausal. Which of the following statements indicates that the nurse should screen the client for depression? - ANSWER "My family doesn't need me anymore. I've failed them in so many ways." A nurse is preparing to administer a topical medication to a client. Which of the following actions should the nurse take first? - ANSWER Compare the label of the medication container with the medication adminstration record three times. A nurse is reinforcing teaching with a client about using guided imagery. Which of the following actions should the nurse take? - ANSWER Direct the client to visualize tension leaving the body. A charge nurse is reinforcing teaching with an assistive personnel (AP) about performing pulse oximetry. Which of the following information should the nurse include in the teaching? - ANSWER Remove polish from client's fingernail before applying oximetry probe. A nurse is calculating the intake and output for a client over the last 8 hours. The client is receiving a continuous IV infusion at 150 mL/hr and had 4 oz of juice and 0.5 L of water. How many mL of fluid should the nurse document as the client's intake for the last 8 hours? (Round your answer to the nearest whole number) - ANSWER 1820 mL A nurse is preparing to administer oxygen to a client who has heart failure and is having severe difficulty breathing. Which of the following oxygen delivery equipment should the nurse select to provide the highest concentration of oxygen to the client? - ANSWER Nonrebreather mask A client who has a recent below-the-knee amputation says, "I don't know how i can continue to live my life without my leg." Which of the following responses should the nurse make? - ANSWER "Tell me what concerns you have about your future." A nurse is reinforcing teaching about the use of crutches with a client who has a fractured right tibia and fibula. Which of the following statements by the client indicates an understanding of the teaching? - ANSWER I will be sure to keep the crutch tips dry A nurse is reviewing the vital signs of four clients. Which of the following requires further data collection by the nurse? - ANSWER A client who has a pulse of 110/min