Fundamentals 2
A nurse is checking the IV insertion site for infiltration for a client who is receiving fluid
replacement. Which of the following findings should the nurse identify is infiltration of the
IV infusion site? - -Taut skin around the IV catheter site that is cool to the touch
A nurse is preparing to anchor with tape the catheter tube for a male client who has a newly
inserted indwelling urinary catheter. At which of the following locations should the nurse
tape the catheter? - -Lower abdomen
A nurse is caring for a group of clients who are receiving oxygen therapy. Which of the
following clients should the nurse plan to see first? - -A client who has heart failure
and is receiving 100% oxygen via a partial rebreather mask
A nurse is contributing to the plan of care for a client who is confused and requires a
prescription for wrist restraints. Which of the following interventions should the nurse
include in the plan of care? - -Renew the prescription for the use of restraints within
24 hr.
A nurse is preparing to administer an intramuscular injection to a client who is overweight.
Which of the following sites should the nurse select for the injection? - -The side hip
between the iliac crest and anterior iliac spine
A nurse is caring for a client who has a history of dysrhythmias. Upon entering the room,
the nurse discovers the client is unresponsive to verbal or painful stimuli, has no
respirations, and is pulseless. Which of the following actions should the nurse take first? -
-Start chest compressions
A nurse is helping a client change his hospital gown. The client has an IV infusion on an
infusion pump. Which of the following actions should the nurse take first? - -Remove
the sleeve of the gown from the arm without the IV line.
, Fundamentals 2
A nurse is caring for a client who has a prescription for collection of a sputum specimen for
culture and sensitivity. Which of the following actions should the nurse plan to take when
obtaining the specimen? - -Collect specimen upon arising in the morning
A nurse is administering a cleansing enema to a client who is scheduled for a diagnostic
procedure. Which of the following actions should the nurse take? - -Insert the tip of
the tubing 8 cm (3.1 in)
A nurse us caring for a client who has an NG tube for intermittent enteral feedings. Which of
the following actions should the nurse take? - -Elevate the client's head of bed 45
degrees before the feeding
A nurse is preparing to administer eye drops to a client following surgery. Which of the
following actions should the nurse take when instilling the eye drops? - -Drop the eye
medication in the outer third of the lower conjunctival sac
A nurse is applying antiembolitic stockings for a client who has a history of deep vein
thrombosis. Which of the following actions should the nurse take when applying the
stockings? - -Turn the stocking inside out up to the heel before applying
A nurse is preparing to remove an NG tube for a client who had a partial colectomy. Which
of the following actions should the nurse take? - -Pinch the NG tube while removing
the tube.
A nurse is performing eye irrigation for a client who was exposed to smoke and ash. Which
of the following actions should the nurse take? - -Exert pressure on the pony
prominences when holding the eyelids open
A nurse is checking the IV insertion site for infiltration for a client who is receiving fluid
replacement. Which of the following findings should the nurse identify is infiltration of the
IV infusion site? - -Taut skin around the IV catheter site that is cool to the touch
A nurse is preparing to anchor with tape the catheter tube for a male client who has a newly
inserted indwelling urinary catheter. At which of the following locations should the nurse
tape the catheter? - -Lower abdomen
A nurse is caring for a group of clients who are receiving oxygen therapy. Which of the
following clients should the nurse plan to see first? - -A client who has heart failure
and is receiving 100% oxygen via a partial rebreather mask
A nurse is contributing to the plan of care for a client who is confused and requires a
prescription for wrist restraints. Which of the following interventions should the nurse
include in the plan of care? - -Renew the prescription for the use of restraints within
24 hr.
A nurse is preparing to administer an intramuscular injection to a client who is overweight.
Which of the following sites should the nurse select for the injection? - -The side hip
between the iliac crest and anterior iliac spine
A nurse is caring for a client who has a history of dysrhythmias. Upon entering the room,
the nurse discovers the client is unresponsive to verbal or painful stimuli, has no
respirations, and is pulseless. Which of the following actions should the nurse take first? -
-Start chest compressions
A nurse is helping a client change his hospital gown. The client has an IV infusion on an
infusion pump. Which of the following actions should the nurse take first? - -Remove
the sleeve of the gown from the arm without the IV line.
, Fundamentals 2
A nurse is caring for a client who has a prescription for collection of a sputum specimen for
culture and sensitivity. Which of the following actions should the nurse plan to take when
obtaining the specimen? - -Collect specimen upon arising in the morning
A nurse is administering a cleansing enema to a client who is scheduled for a diagnostic
procedure. Which of the following actions should the nurse take? - -Insert the tip of
the tubing 8 cm (3.1 in)
A nurse us caring for a client who has an NG tube for intermittent enteral feedings. Which of
the following actions should the nurse take? - -Elevate the client's head of bed 45
degrees before the feeding
A nurse is preparing to administer eye drops to a client following surgery. Which of the
following actions should the nurse take when instilling the eye drops? - -Drop the eye
medication in the outer third of the lower conjunctival sac
A nurse is applying antiembolitic stockings for a client who has a history of deep vein
thrombosis. Which of the following actions should the nurse take when applying the
stockings? - -Turn the stocking inside out up to the heel before applying
A nurse is preparing to remove an NG tube for a client who had a partial colectomy. Which
of the following actions should the nurse take? - -Pinch the NG tube while removing
the tube.
A nurse is performing eye irrigation for a client who was exposed to smoke and ash. Which
of the following actions should the nurse take? - -Exert pressure on the pony
prominences when holding the eyelids open
