NURS 100 fundamental final
A nurse is teaching a client how to self-administer insulin. Which of the following actions
should the nurse take to evaluate the clients understanding of the process within the
psychomotor domain of learning? - Have the client demonstrates the procedure
a nurse is preparing to administer a cleansing enema to a client. Which of the following
actions should the nurse plan to take? - Position the client on his left side
A client who reports shortness of breath requests her nurse's help in changing positions.
After repositioning the client, which of the following actions should the nurse take next?
- Observe the rate, depth, and character of the client's respirations.
A nurse is caring for a client who has bilateral casts on her hands. Which of the
following actions should the nurse take when assisting the client with feeding? - Sit at
the bedside while feeding the client.
A nurse is caring for a client who, while sitting in a chair, starts to experience a seizure.
Which of the following actions should the nurse take? - lower the client to the floor and
place a pad under the client's head.
a home health nurse is planning to provide health promotion activities for a group of
clients in the community. Which of the following activities is an example of the nurse
promoting primary prevention? - Educating clients about the recommended
immunization schedule for adults.
Assistive personnel (AP) is assisting a nurse with the care of a female client who has an
indwelling urinary catheter. Which of the following actions by the AP indicates a need for
further teaching? - The AP hangs the collection bag at the level of the bladder.
Timeframes for STAT, routine, and now orders - 5 minutes for stat
30 before/after for routine
90 minutes for now orders
A nurse is providing discharge teaching to a client who is recovering from lung cancer.
The provider instructed the client that he could resume lower-intensity activities of daily
living. Which of the following activities should the nurse recommend to the client? -
washing dishes
A nurse is planning to perform passive range-of-motion exercises for a client. Which of
the following actions should the nurse take? - repeat each joint motion five times during
each session.
A nurse is planning care for a client who has a single-lumen nasogastric (NG) tube for
gastric decompression. Which of the following actions should the nurse include in the
plan of care?(select all that apply.) - Provide oral hygiene frequently
measure the drainage from the NG tube every shift
Secure the NG tube to the client's gown
, NURS 100 fundamental final
An example of situational crisis and who is at highest risk - unanticipated loss caused by
external factor, and someone with mental health issues.
patient education for aspirin and acetaminophen is - reports bleeding, ringing in ear, and
not taking if 19 with viral infection (aspirin). avoid alcohol, do not exceed 3gm/day, and
routnine blood pressure (acetaminophen)
Name and describe 4 landmarks for IM injections - Deltoid
vastus lateralis
ventrogluteal
dorsogluteal
determining orthostatic hypotension - Technique: BP & HR in supine then change to
sitting/standing (wait 1-3 mins) BP & HR if SBP dec. More than 20 mm hg and/or DBP
dec. more than 10 mm hg w/ a 10-20% inc. in hr=orthostatic hypotension
Diet should include this to help in wound healing - Protein
What solution is used to clean wound before obtaining specimen? - 0.9% sodium
chloride (normal saline)
Describe dehisence/evisceration and nursing interventions - Dehisence partial or total
separation of wound and evisceration os dehisence with protrusion of viseral organs
through wound opening. Medical emergency, cover wound with moistened sterile
gauze.
What are the five types of wound exudate (drainage and describe? - Serous(clear,
watery), purulent (yellow/green/brown), serosanguineous (pink watery),
sanguineous(red), and purspsanguineous (pus and blood)?s
name and describe each pressure ulcer - Stage I (erythematous non-blanchable)
Stage II (exposed dermis-partial thickness loss)
Stage III (subcutaneous tissue, full-thickness loss, slough.eschar)
Stage IV ( muscle, tendon, bone, full-thickness loss, slough/eschar), unstageable (can't
determine extent, full-thickness, need to do)
AND stands for - allow natural death
Four CS of a cultural/spiritual assessment is? - Call
Cope
Concerns
Cause
Main difference between palliative care and hospice care? - less than 6 months to live
A nurse is teaching a client how to self-administer insulin. Which of the following actions
should the nurse take to evaluate the clients understanding of the process within the
psychomotor domain of learning? - Have the client demonstrates the procedure
a nurse is preparing to administer a cleansing enema to a client. Which of the following
actions should the nurse plan to take? - Position the client on his left side
A client who reports shortness of breath requests her nurse's help in changing positions.
After repositioning the client, which of the following actions should the nurse take next?
- Observe the rate, depth, and character of the client's respirations.
A nurse is caring for a client who has bilateral casts on her hands. Which of the
following actions should the nurse take when assisting the client with feeding? - Sit at
the bedside while feeding the client.
A nurse is caring for a client who, while sitting in a chair, starts to experience a seizure.
Which of the following actions should the nurse take? - lower the client to the floor and
place a pad under the client's head.
a home health nurse is planning to provide health promotion activities for a group of
clients in the community. Which of the following activities is an example of the nurse
promoting primary prevention? - Educating clients about the recommended
immunization schedule for adults.
Assistive personnel (AP) is assisting a nurse with the care of a female client who has an
indwelling urinary catheter. Which of the following actions by the AP indicates a need for
further teaching? - The AP hangs the collection bag at the level of the bladder.
Timeframes for STAT, routine, and now orders - 5 minutes for stat
30 before/after for routine
90 minutes for now orders
A nurse is providing discharge teaching to a client who is recovering from lung cancer.
The provider instructed the client that he could resume lower-intensity activities of daily
living. Which of the following activities should the nurse recommend to the client? -
washing dishes
A nurse is planning to perform passive range-of-motion exercises for a client. Which of
the following actions should the nurse take? - repeat each joint motion five times during
each session.
A nurse is planning care for a client who has a single-lumen nasogastric (NG) tube for
gastric decompression. Which of the following actions should the nurse include in the
plan of care?(select all that apply.) - Provide oral hygiene frequently
measure the drainage from the NG tube every shift
Secure the NG tube to the client's gown
, NURS 100 fundamental final
An example of situational crisis and who is at highest risk - unanticipated loss caused by
external factor, and someone with mental health issues.
patient education for aspirin and acetaminophen is - reports bleeding, ringing in ear, and
not taking if 19 with viral infection (aspirin). avoid alcohol, do not exceed 3gm/day, and
routnine blood pressure (acetaminophen)
Name and describe 4 landmarks for IM injections - Deltoid
vastus lateralis
ventrogluteal
dorsogluteal
determining orthostatic hypotension - Technique: BP & HR in supine then change to
sitting/standing (wait 1-3 mins) BP & HR if SBP dec. More than 20 mm hg and/or DBP
dec. more than 10 mm hg w/ a 10-20% inc. in hr=orthostatic hypotension
Diet should include this to help in wound healing - Protein
What solution is used to clean wound before obtaining specimen? - 0.9% sodium
chloride (normal saline)
Describe dehisence/evisceration and nursing interventions - Dehisence partial or total
separation of wound and evisceration os dehisence with protrusion of viseral organs
through wound opening. Medical emergency, cover wound with moistened sterile
gauze.
What are the five types of wound exudate (drainage and describe? - Serous(clear,
watery), purulent (yellow/green/brown), serosanguineous (pink watery),
sanguineous(red), and purspsanguineous (pus and blood)?s
name and describe each pressure ulcer - Stage I (erythematous non-blanchable)
Stage II (exposed dermis-partial thickness loss)
Stage III (subcutaneous tissue, full-thickness loss, slough.eschar)
Stage IV ( muscle, tendon, bone, full-thickness loss, slough/eschar), unstageable (can't
determine extent, full-thickness, need to do)
AND stands for - allow natural death
Four CS of a cultural/spiritual assessment is? - Call
Cope
Concerns
Cause
Main difference between palliative care and hospice care? - less than 6 months to live
