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Fundamentals
| Question | Answer |
|---|---|
| Which action should the nurse implement when adding sterile liquids to a sterile field? | Consider the sterile field contaminated if it becomes wet during the procedure |
| The charge nurse assigns a nursing procedure to a new staff nurse who has not previously performed the procedure. Which action is most important for the new staff nurse to take? | Inform the charge nurse that they have never done this procedure. |
| When preparing to administer an intravenous medication through a central venous catheter, the nurse aspirates a blood return in one of the lumens of the triple lumen catheter. Which action should the nurse implement? | Flush the lumen with the saline solution and administer the medication through the lumen. |
| The nurse formulates the nursing problem of, "Ineffective health maintenance related to lack of motivation" for a client with Type 2 diabetes. Which finding supports this nursing problem? | Eats anything and does not think diet makes a difference in health. |
| A low-sodium, low-protein diet is prescribed for a 45-year-old client with renal insufficiency and hypertension, who gained 3 pounds in the last month. The nurse determines that the client has been noncompliant with the diet, based on which report from th | Snack of potato chips and diet soda. Lunch of tuna fish sandwich, carrot sticks, fresh fruit, and coffee. Breakfast of eggs, bacon, toast, and coffee. |
| Which intervention should the nurse include in the plan of care for a client who is being treated with compression dressings for leg ulcers due to chronic venous insufficiency? | Check capillary refill of toes on the lower extremity with venous compression dressings. |
| A 35-year-old female client with cancer refuses to allow the nurse to insert an IV for a scheduled chemotherapy treatment and states that she is ready to go home to die. Which intervention should the nurse initiate? | Evaluate the client's mental status for competence to refuse treatment. |
| Which action is most important for the nurse to implement when placing a client in the lateral recumbent position? | Raise the bed to a waist-high working level. |
| While the nurse is administering a bolus feeding to a client via a nasogastric tube, the client begins to vomit. Which action should the nurse implement first? | Discontinue the administration of the bolus feeding. |
| In assessing a client's femoral pulse, the nurse must use deep palpation to feel the pulsation while the client is in a supine position. Which action should the nurse implement? | Document the presence and volume of the pulse palpated. |
| A 4-year-old boy who is scheduled for a tonsillectomy and adenoidectomy asks the nurse, "Will it hurt to have my tonsils and adenoids taken out?" Which response is best for the nurse to provide? | "It may hurt but we'll give you medicine to help you feel better." |
| The nurse is administering an intermittent infusion of an antibiotic to a client whose intravenous (IV) access is an antecubital saline lock. After the nurse opens the roller clamp on the IV tubing, the alarm on the infusion pump indicates an obstruction. | Reposition the client's arm. |
| The nurse is preparing to irrigate a client's indwelling urinary catheter using an open technique. Which action should the nurse take after applying gloves? | Draw up the irrigating solution into the syringe. |
| A nurse is becoming increasingly frustrated by the family members' efforts to participate in the care of a hospitalized client. Which action should the nurse implement to cope with these feelings of frustration? | Examine one's own culturally based values, beliefs, attitudes, and practices. |
| The nurse encounters a slight resistance when inserting the tubing into a client's rectum for a tap water enema. Which action should the nurse implement? | Ask the client to relax and twist the tube gently through the sphincter. |
| To obtain the most complete assessment data for a client with chronic pain, which information should the nurse obtain? | Which activities during a routine day are impacted by your pain? |
| A male client arrives at the outpatient surgery center for a scheduled needle aspiration of the knee. He tells the nurse that he has already given verbal consent for the procedure to the healthcare provider. Which action should the nurse pursue next? | Verify the client's consent with the healthcare provider. |
| Which statement is an example of a correctly written nursing problem statement? Altered tissue perfusion related to heart failure. Altered urinary elimination related to urinary tract infection. Risk for impaired tissue integrity related to the client's | Ineffective coping related to an inadequate level of perception of control. |
| The nurse is completing the plan of care for a client who is admitted for benign prostatic hypertrophy. Which data should the nurse document as a subjective finding? | Reports inability to empty bladder. |
| Which statement correctly identifies a written learning objective for a client with peripheral vascular disease? | Upon discharge, the client will list three ways to protect the feet from injury. |
| A client is admitted with a stage four pressure injury that has a black, hardened surface (eschar) that is stable. Which dressing is best for the nurse to use first? | No dressing. |
| A client provides the nurse with information about the reason for seeking care. The nurse realizes that some information about past hospitalizations is missing. How should the nurse obtain this information? | Elicit specific facts about past hospitalizations with direct questions. |
| When caring for an immobile client, what nursing problem has the highest priority? | Impaired gas exchange. |
| While caring for a child and mother from an Asian culture, which action should the nurse implement to accommodate the clients' cultural needs? | Speak initially with the oldest family member to show respect. |
| The nurse determines a client's IV solution is infusing at 250 mL/hr. The prescribed rate is 125 mL/hr. Which action should the nurse take first? | Slow the IV infusion to keep vein open rate. |
| A male client with venous incompetence stands up and his blood pressure subsequently drops. Which finding should the nurse identify as a compensatory response? | Increase in pulse rate. |
| A male client has a nursing problem of "spiritual distress." Which intervention is best for the nurse to implement when caring for this client? | Use reflective listening techniques when the client expresses spiritual doubts. |
| A client has a nursing problem of, "Spiritual distress related to a loss of hope, secondary to impending death." Which intervention is best for the nurse to implement when caring for this client? | Assist and support the client in establishing short-term goals. |
| The nurse working in the emergency department is assessing four clients' ability to tolerate pain. Which client is likely to tolerate a higher level of pain? | A 55-year-old woman who has had moderate low back pain for three months. |
| Prior to administering a newly prescribed medication to a client, the nurse reviews the adverse effects of the medication listed in a drug reference guide and determines the priority risks to the client. While performing this action, the nurse is engaged | Analysis. |
| Which nursing intervention is most beneficial in reducing the risk of urosepsis in a hospitalized client with an indwelling urinary catheter? | Obtain a prescription for removal of the catheter as soon as possible. |
| A female client informs the nurse that she uses herbal therapies to supplement her diet and manage common ailments. Which information should the nurse offer the client about the general use of herbal supplements? | Herbs should be obtained from manufacturers with a history of quality control of their supplements. |
Created by:
Breanda21