Fundamentals Practice
1.A nurse is administering 1 L of 0.9% sodium chloride to a client who is postoperative and
has fluid volume deficit. Which of the following changes should the nurse identify as an indication that the treatment was successful?
a.Decrease in heart rate
b.Fluid volume deficit causes tachycardia
2.A nurse working in the emergency department is witnessing the signing of informed consent forms for the treatment of multiple clients during her shift. Which of the following
signatures may the nurse legally witness?
a.A 16 y/o client who is married
b.A 27 y/o who has schizophrenia
c.An adoptive parent who brings in his 8 yo son
d.A 17 year old mother who brings in her toddler.
3.A nurse is caring for a client who has a respiratory infection. Which of the following techniques should the nurse use when performing nasotracheal suctioning for the client?
a.Appy intermittent suction when withdrawing the catheter
4.A nurse is teaching a client about dietary management of hypercholesterolemia. Which of the following foods should the nurse suggest that the client add to his diet?
a.Avocados
b.Avocados contain no cholesterol
5.A nurse is preparing to transfer a client who can bear weight on one leg from the bed to a chair. After securing a safe environment, which of the following actions should the nurse take next?
a.Assess the client for orthostatic hypotension
b.The first action should be to assess the patient and determine if the patient is at risk for falling or fainting during the transfer.
6.A nurse is caring for a group of clients. Which of the following should the nurse take to prevent the spread of infection. a.Place a client who has TB in a room with negative pressure airflow
b.A client who has TB requires airborne precautions
7.A nurse is caring for a client who does not speak the same language as the nurse. When
working with the client through an interpreter, which of the following actions should the nurse take?
a.Talk directly to the client, instead of the interpreter, when speaking. 8.A nurse is caring for a client who has an indwelling urinary catheter. Which of the following assessment findings indicates that the catheter requires irrigation?
a.Bladder scan shows 525 mL or urine
b.A client who has an indwelling catheter should have continuous urine flow w/o an
accumulation of urine in the bladder
9.A nurse is caring for a client who has diarrhea due to shigella. Which of the following precautions should the nurse take?
a.Wash her hands before and after contact with the client
b.Shigella requires the nurse to perform contact precautions to prevent the This study source was downloaded by 100000830916879 from CourseHero.com on 01-05-2022 06:47:19 GMT -06:00
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10.A nurse on a medical unit is preparing to discharge a client to home. Which of the following actions should the nurse take as part of the medication reconciliation process?
a.Compare prescriptions with medications the client received during hospitalization.
b.When performing reconciliation, the nurse should create a current, accurate list of every medication the client is or should be taking. 11.A nurse is preparing to insert an IV catheter into a client’s arm prior to initiating IV fluid therapy. Which of the following interventions should the nurse implement to prevent infection?
a.Thread the catheter up to the hub reduces the risk of contamination along the length of the catheter.
b.Inserting the catheter up to the hub reduces the risk of contamination along the length of the catheter
12.A nurse is caring for a client who needs to maintain a positive nitrogen balance for wound healing. Which of the following food items should the nurse recommend as a good source of complete protein?
a.Cheddar cheese
b.Complete proteins contain enough of all nine of the essential amino acids that help maintain and promote nitrogen balance. Cheese, poultry, and fish are good sources of complete protein.
13.A nurse is providing discharge teaching to a client who has a new prescription for a home oxygen concentrator. Which of the following instructions should the nurse provide to the client and his family?
a.Check the cord routinely for frays or tearing
b.Consider purchasing a generator for power backup
c.Observe for signs of hypoxia
d.Clothing and bedding should not be made from synthetic fabric b/c it can generate static electricity, the client should wear cotton instead. Oxygen equipment should be at least 10 feet away from open flames (gas stove, fireplace).
14.A nurse receives a report about a client who has 0.9% sodium chloride infusing IV at 125
mL/hr. When the nurse performs the initial assessment, he notes that the client has received only 80 mL over the last 2 hrs. Which of the following actions should the nurse take first?
a.Check the IV tubing for obstruction
15.A nurse is planning care for a client who has fluid overload. Which of the following actions should the nurse plan to take first?
a.Evaluate electrolytes
b.Assess the client’s electrolytes first/lab results, including sodium, potassium, BUN, Hgb, Hct, and protein, to guide the planning of interventions to correct the imbalances. You should not restrict intake of oral fluids first.
16.A nurse is planning to initiate IV therapy for an older adult client who requires IV fluids. Which of the following actions should the nurse take?This study source was downloaded by 100000830916879 from CourseHero.com on 01-05-2022 06:47:19 GMT -06:00
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