Fundamentals Practice Quiz 2
A nurse is caring for a toddler when the mother calls to the nurse "Help! My baby is choking on his food!. Which of the following findings indicate the baby has an airway obstruction?
Flushing of the skin
Inability of the toddler to cry or speak
Presence of nausea and mild emesis
Capillary refill time of 1.5 seconds - answer Inability of the toddler to cry or speak
A nurse is planning care for a client who has a prescription for a collection of sputum specimen for culture and sensitivity. Which of the following actions should the nurse take when obtaining the specimen? Collect the specimen upon arising in the morning
Force fluids during the day and collect the specimen in the evening
Collect the specimen after antibiotics have been started.
Collect 2 mL of sputum before sending the specimen to the lab. - answer Collect the specimen upon arising in the morning
A nurse is performing eye irrigation for a client who has been exposed to smoke and ash. Which action should the nurse take?
Hold the irrigator 1.25 cm (0.5 in) above the eye.
Direct the irrigation solution upward toward the upper eyelid.
Exert pressure on the bony prominences when holding the eyelids open.
Direct the irrigation from the outer canthus to the inner canthus of the eye. - answer Exert pressure on the bony prominences when holding the eyelids open.
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?
Maintain suction while removing the NG tube
Instill 100 mL of air into the NG tube before removal
Pinch the NG tube when removing the tube
Instruct the client to breathe in and out during the removal of the NG tube. - answer Pinch the NG tube while removing the tube
Where should the nurse administer an intramuscular injection an adult client who is overweight? Lower, medial quadrant of buttock near the coccyx
Side hip between iliac crest and anterior iliac spine
Tissue of posterior upper arm
Lower, inner thigh 4 finger widths above the patella - answer Side hip between the iliac crest and anterior iliac spine
A nurse is changing bed linens for a client who is on bed rest. Which action should the nurse take?
Place the soiled linens on the chair while making the bed.
Hold the linens away the body and clothing
Place the linens on the floor until able to place it in a linen bag.
Shake the clean linens to unfold. - answer Hold the linens away from the body and clothing
The nurse observes yellow, thick drainage on the dressing for a client who is 3 days post-operative from cholecystectomy. How should she document this finding?
Sanguineous exudate
Serous exudate
Serosanguineous exudate
Purulent exudate - answer Purulent exudate
A nurse is caring for an older adult client who has dysphagia. Which action should the nurse take when assisting the client at mealtime?
Encourage the client to drink fluids before swallowing food.
Offer the client tart or sour foods first.
Tilt the client's head backward when swallowing
Turn on the television - answer Offer the client tart or sour foods first
A nurse is changing the dressings for a client who has two Penrose drains near an abdominal incision. Which of the following adhering devices is the best choice for skin irritation?
Abdominal binder
Montgomery straps
Hypoallergenic tape
Plastic tape - answer Montgomery straps
How should a nurse administer eye drops in a post-surgical patient?
Drop the eye medication in the outer third of the lower conjunctival sac. Apply gentle pressure in the outer opening of the eye for 2 minutes. Hold the eye dropper 0.5 cm/ 0.2 in from the cornea.
Instruct the client to close eyes tightly after administration - answer Drop the eye medication in the outer third of the lower conjunctival sac.
A nurse is caring for a client with major fecal incontinence and reports irritation in the perineal area. Which of the following action should the nurse take first?
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