NRS-2024 FUNDAMENTAL Exam 1 Review:
A client has a diagnosis of HIV and has been admitted to the hospital with an opportunistic
infection that originated with the client's normal flora. Why did this client most likely become ill
from his resident microorganisms? - ANS-The client's immune system became further
weakened
A client has sought care because of a knee wound that appears to have become infected.
Which process is a component of the cellular stage of inflammation that occurred earlier in his
body's response to infection? - ANS-Migration of leukocytes to the area of the wound
A client has very dry skin. Which is the best intervention for the nurse to teach the client? -
ANS-the client should bath in warm water for 20 min and then apply lotion immediately because
this will keep the moisture in the skin
A client is very anxious and states, "I am so stressed". Why do these factors affect the client's
safety? - ANS-stress tends to narrow attention span
A client who has been lying prone reports shortness of breath and a sensation of choking. Into
which position will the nurse place the client? - ANS-Fowler's
A client with diabetes has impaired sensation in her lower extremities. What education would be
necessary to reduce her risk of injury? - ANS-Always test the temp of bath water before
stepping in"
A hospital utilizes the SOAP method of charting. Within this model, which of the nurse's
following statements would appear at the beginning of a charting entry? - ANS-Client
complaining of abdominal pain rated at 8/10.
A middle-aged, overweight adult man has had hypertension for 15 years. What pathologic event
is he most at risk for? - ANS-stroke
A nurse educator is teaching a patient about a healthy diet. What information would be included
to reduce the risk of hypertension? - ANS-Put away the salt shaker and eat low-salt [sodium,
Na] foods.
A nurse enters a client's room and finds that the client has fallen on her way to the bathroom.
Which of the following is a prudent nursing intervention for this client? - ANS-Document incident
report, assessment, & intervention in the client's medical record.
, A nurse has finished providing care for a client who is on contact precautions. When removing
the protective gown, the nurse should take which action? - ANS-Avoid touching the outer
surfaces of the gown
A nurse in an oncology care unit is reviewing the laboratory test results of several clients. The
nurse identifies that the client with which leukocyte count most likely has an infection? -
ANS-18,000 cells/mm.
Reasoning: elevated WBC count is a sign of infection. Normal WBC is 5,000-10,000
A nurse is assessing a client for signs and symptoms of infection. What would the nurse expect
to asses? Select all that apply.
A.) Decreased pulse rate
B.) Increased respiratory rate
C.) Absence of pain
D.) Lymph node enlargement
E.) Fever - ANS-B, D, & E
A nurse is conducting a health history for a client with a chronic respiratory problem. What
question might the nurse ask to assess for orthopnea? - ANS-How many pillows do you sleep
on at night to breathe better?
A nurse is providing oral care to a patient with dentures. What action would the nurse do first? -
ANS-don gloves
A nurse is providing perineal care to a female patient. In which direction would the nurse move
the washcloth? - ANS-from the pubic area toward the anal area
A nurse is working as part of a team that has been asked to address the issue of confidentiality
and documentation of client health information electronically. Which activity(ies) would the team
suggest to help ensure confidentiality? Select all that apply.
A.) Having each person responsible for documenting in the electronic health record not share
his or her password
B.) Placing computer screens in locations that face away from any public areas such as
hallways
C.) Ensuring that individuals log off a computer terminal when documentation is completed
D.) Promoting the sharing of printers among several units
E.) Allowing confidential emails to be sent via a public network - ANS-A,B,& C
A nurse makes a medication error and fills out an incident report what will the nurse do with the
incident report once it is filled out? - ANS-Maintain it according to agency policy
A nurse manager is discussing a nurse's social media post about an interesting client situation.
The nurse states, "I didn't violate client privacy because I didn't use the client's name." What
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