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Fundamentals 2023 Proctor Questions and Answers
A charge nurse is reinforcing teaching with a newly licensed nurse who is setting up a sterile field. Which of the following actions by the newly licensed nurse indicates an understanding of the teaching? opening the first flap of a sterile package toward herself dropping sterile gauze onto the field from a height of 7.5 cm (3 in) removing and inverting a lid before placing it onto a nonsterile surface maintaining the sterile field below waist level. - ansremoving and inverting a lid before placing it onto a nonsterile surface A nurse and an assistive personnel (AP) are providing postmortem care for a decease client prior to visitation by the family. Which of the following actions by the AP requires intervention by the nurse? Fathering the client's personal belongings. Removing the client's dentures. Placing absorbent pads under the client's buttocks. Closing the client's eyes. - ansRemoving the client's dentures. A nurse assisting with the admission of a client to a medical-surgical unit. Which of the following findings should the nurse identify as an indication that the client is malnourished? Heart rate 89/min. Pink mucous membranes. Pallor with scaly skin. Body mass index 23 - ansPallor with scaly skin. A nurse in reinforcing teaching about carbohydrate counting with a client who has a new diagnosis of diabetes mellitus. Which of the following actions should the nurse take first? Use pictures of different food groups to help the client plan a daily menu.
Ask the client what they already know about meal planning. Give the client a brochure with sample menus for all meals. Involve the family in the discussion of the client's meal plan. - ansAsk the client what they already know about meal planning. A nurse is assisting with the admission of an adult client to a medical-surgical unit. Which of the following findings should the nurse identify as an indication that the client is malnourished? heart rate 89/min pink mucous membranes pale, scaly skin body mass index 23 - anspale, scaly skin A nurse is assisting with the care of a client who has a prescription for IV therapy. The client tells the nurse that he has numerous allergies. Which of the following allergies should the nurse bring to the attention of the charge nurse prior to the initiation of the therapy? eggs latex seafood bee stings - anslatex A nurse is caring for a client who has a new diagnosis of cancer. Which of the following actions by the nurse maintains the client's confidentiality? Sharing the client's prognosis with a member of the client's family. Discussing the client's status with a member of the spiritual support team. Collaborating with a nurse from another unit about the client's care. Providing client information to another nurse at change of shift. - ansProviding client information to another nurse at change of shift.
flush the catheter with sterile water daily disconnect the drainage bag when emptying and measuring urine - ansclean the perineal area at least once a day A nurse is caring for a client who has an indwelling urinary catheter. Which of the following actions should the nurse take? Clean the perineal area at least once a day. Empty the drainage bag when it is three-fourths full. Flush the catheter with sterile water daily. Disconnect the drainage bag when emptying and measuring urine. - ansClean the perineal area at least once a day. A nurse is caring for a client who has been vomiting and has diarrhea. Which of the following findings should the nurse identify as an indication of fluid volume deficit? BUN 18 mg/dL. A thready pulse. Hemoglobin 15 g/dL. Prominent neck veins. - ansA thready pulse. A nurse is caring for a client who has been vomiting excessively and has diarrhea. Which of the following findings should the nurse identify as an indication of fluid volume deficit? BUN 18 mg/dL a bounding pulse urine specific gravity 1. prominent neck veins - ansurine specific gravity 1. A nurse is caring for a client who has chronic kidney disease. The nurse should identify that which of the
following findings is the priority? client reports voiding three times during the night client reports burning and discomforting with urination the client's WBC count is 11,000/mm^ the client's output was 60 mL for the past 3 hr - ansthe client's output was 60 mL for the past 3 hr A nurse is caring for a client who has chronic pain. The nurse recommends that the client concentrate on a memory of a pleasurable experience. Which of the following complementary therapies is the nurse suggesting? Art therapy. Tai chi. Guided imagery. Biofeedback. - ansGuided imagery. A nurse is caring for a client who has dyspnea caused by a respiratory infection. The nurse should assist the client into which of the following positions. Orthopneic. Dorsal recumbent. Sims' Prone - ansOrthopneic. A nurse is caring for a client who has limited mobility. Which of the following actions should the nurse take to maintain the client's skin integrity? Use warm water when bathing the client. Place a donut shaped cushion in the client's chair. Massage reddened areas over bony prominences.
Measure the client's gastric residual before each feeding. Change the bag and tubing every 24 hours. Document intake and output. Flush the tubing with 30 mL of water after each feeding. - ansMeasure the client's gastric residual before each feeding. A nurse is caring for a client who is scheduled for surgery the following day. During the night, the client is unable to sleep and is restless. Which of the following statements should the nurse make? "It must be difficult facing this type of surgery." "Other clients who have had this surgery have done just fine." "This facility is known for providing excellent care for people who need this type of surgery." "I can request a sleeping pill, if you think that will help." - ans"It must be difficult facing this type of surgery." A nurse is caring for a client who reports difficulty sleeping at home. Which of the following recommendations should the nurse provide to promote a restful home sleep environment? "Perform muscle relaxation before bedtime." "Exercise vigorously 1 hour prior to going to bed." "Drink a cup of hot chocolate at bedtime." "Change the time you go to sleep each day. - ans"Perform muscle relaxation before bedtime." A nurse is caring for a client who reports itching 30 min after receiving a newly prescribed medication. Which of the following data should the nurse document in the client's medical record? Client is itching from medication. Client states, "I started to itch after taking that medication." It appears that the client has a rash from the medication. Rash from medication noted. - ansClient states, "I started to itch after taking that medication."
A nurse is caring for a group of clients in a long-term care facility. Which of the following actions should the nurse take to prevent health care-associated infections for these clients? (Select all that apply) -Place immunocompromised clients in the same room. -Wash hands after removing gloves. -Use antimicrobial hand gel after refilling a client's water pitcher -Clean the stethoscope with an antimicrobial wipe after obtaining vital signs. -Administer a prophylactic dose of antibiotics prior to discharge. - ans-Wash hands after removing gloves. -Use antimicrobial hand gel after refilling a client's water pitcher. -Clean the stethoscope with an antimicrobial wipe after obtaining vital signs. A nurse is caring for an older adult client and is concerned that the client may have a fecal impaction. Which of the following is the most important question for the nurse to ask? "What types of foods have you been eating?" "Are you using stool softeners or laxatives?" "Have you been passing gas?" "Have you had small liquid stools?" - ans"Have you had small liquid stools?" A nurse is caring for four clients. For which of the following clients should the nurse use the therapeutic communication technique of silence? a client who plans to leave the facility against medical advice a client who informs the nurse that he has made his funeral arrangements a client who tells the nurse that the night shift nurse did not bring his medication a client who has just experienced the death of his child - ansa client who has just experienced the death of his child A nurse is caring for four clients. For which of the following clients should the nurse use the therapeutic
Headache Difficulty voiding - ansHeadache A nurse is collecting data from a client who is 1 day postoperative following abdominal surgery. Which of the following findings is the priority for the nurse to report to the provider? The client reports incisional pain as 7 on a scale of 0-10. The client reports increased nausea and chills. The client has an oral temperature of 38.5° (101.3° F). The client has tenderness and warmth in their calf. - ansThe client has tenderness and warmth in their calf. A nurse is collecting data from a client who is 2 days postoperative following a colostomy. Which of the following findings should the nurse report to the provider? a purple-colored stoma protrusion of the stoma a small amount of bleeding from the stoma intestinal gas in the pouch - ansa purple-colored stoma A nurse is collecting data from a client who is 2 days postoperative following a colostomy placement. Which of the following findings should the nurse report to the provider? A purple-colored stoma. Protrusion of the stoma. A small amount of bleeding from the stoma. Intestinal gas in the pouch. - ansA purple-colored stoma. A nurse is contributing to the plan of care for a client who is dying. Which of the
following intervention should the nurse recommend to include the client's family in the plan of care? (Select all that apply.) -Keep the family updated about the client's status. -Suggest that family members return home at night to allow the client to rest. -Encourage the family to comb the client's hair. -Tell the client's family what to expect as the client's death nears.
- Ask the family to encourage the client to eat - ans-Keep the family updated about the client's status. -Encourage the family to comb the client's hair. -Tell the client's family what to expect as the client's death nears. A nurse is contributing to the plan of care for a client who is dying. Which of the following interventions should the nurse recommend to include the client's family in the plan of care? (Select all that apply.) keep the family updated about the client's status Suggest the family members return home at night to allow the client to rest encourage the family to comb the clients hair tell the client's family what to expect as the client's death nears ask the family to encourage the client to eat - anskeep the family updated about the client's status A nurse is contributing to the plan of care for a client who practices Islam. Which of the following questions should the nurse ask the client to clarify her religious preferences? "Do you receive Holy Communion?" "Do you follow a kosher diet?" "Do you consume pork products?" "Do you oppose receiving a blood transfusion if it is needed?" - ans"Do you consume pork products?" A nurse is contributing to the plan of care for a client who practices Islam. Which of the following questions should the nurse ask the client to clarify the client's religious preferences?
Which of the following actions should the nurse take? Sit beside the client. Speak slowly and loudly. Dim the lights in the client's room. Choose a private room for the interview. - ansChoose a private room for the interview. A nurse is planning care for a group of clients. The nurse should expect to witness an informed consent for a client who will undergo which of the following procedures? Administration of an enema. Performance of a paracentesis. Insertion of an indwelling urinary catheter. Placement of an NG tube. - ansPerformance of a paracentesis. A nurse is planning to administer medication to a client who has a Clostridium difficile infection. Which of the following actions should the nurse plan to take to prevent the transmission of this infection to others? Clean hands with an alcohol-based hand rub immediately after removing gloves. Remove the cover gown in the client's room after providing care. Place the client in a room with negative- pressure airflow Wear a mask when administering oral medications to the client. - ansRemove the cover gown in the client's room after providing care. A nurse is preparing a client for a Romberg test. Which of the following statements should the nurse make? "Stand with your feet together and your arms at your sides." "After I place the turning fork, tell me when you no longer hear the sound." "I'm going to stroke the lateral side of the bottom of your foot." "Touch each fingertip as quickly as possible with your thumb." - ans"Stand with your feet together and your arms at your sides."
A nurse is preparing a client for a Romberg test. Which of the following statements should the nurse make? "Stand with your feet together and your arms at your sides." "After I place the tuning fork, tell me when you no longer hear the sound" "I'm going to stroke the lateral side of the bottom of your foot." "Touch each fingertip as quickly as possible with your thumb." - ans"Stand with your feet together and your arms at your sides." A nurse is preparing to document information about a client's lower legs, which are swollen with 6 mm edema. Which of the following information should the nurse document? 1+ pitting edema 2+ pitting edema 3+ pitting edema 4+ pitting edema - ans3+ pitting edema A nurse is preparing to obtain a clients vital signs. Which of the following actions should the nurse take when washing their hands? Rinse their forearms with running water before applying soap. Hold their hands above elbow level while washing and rinsing. Generate a lather by rubbing their hands together vigorously for 5 seconds. Turn off the faucet with a clean paper towel after drying hands. - ansTurn off the faucet with a clean paper towel after drying hands. A nurse is preparing to perform a wound irrigation for a client who has a stage 3 pressure injury. Which of the following supplies should the nurse plan to use? A piston syringe.
-Place a towel under the client's head with an emesis basin under their chin. -Assess the client's gag reflex. -Cleanse the client's mouth using a toothbrush. -Separate the client's upper and lower teeth with an oral airway device. -Position the client on their side with their head turned to the side. - ans1. Assess the client's gag reflex. 2- Position the client on their side with their head turned to the side. 3- -Place a towel under the client's head with an emesis basin under their chin. 4- Separate the client's upper and lower teeth with an oral airway device. 5- Cleanse the client's mouth using a toothbrush A nurse is reinforcing teaching about advance directives with a client who has end- stage renal disease. Which of the following client statements indicates an understanding of the teaching? a. "I know that i can change my advance directives if I need to in the future." b. "My health care proxy will make my health care decisions as soon as I have signed the power of attorney." c. "My family can overrule the decisions made by my health care proxy." d. "Advance directives from one state are valid in any other state." - ans"I know that i can change my advance directives if I need to in the future." A nurse is reinforcing teaching about advance directives with a client who has end-stage renal disease. Which of the following client statements indicates an understanding of the teaching? "I know that I can change my advance directives if I need to in the future." "My health care surrogate will make my health care decisions as soon as I have signed the power of attorney." "My family can overrule the decisions made by my health care surrogate." "Advance directive from one state are valid in any other state." - ans"I know that I can change my advance directives if I need to in the future."
A nurse is reinforcing teaching about carbohydrate counting with a client who has a new diagnosis of diabetes mellitus. Which of the following actions should the nurse take first? a. use pictures of different food groups to help the client plan a daily menu b. ask the client what he already knows about meal planning c. give the client a brochure with sample menus for all meals d. involve the family in the discussion of the client's meal plan - ansask the client what he already knows about meal planning A nurse is reinforcing teaching with a client about self-administration of ophthalmic drops. Which of the following instructions should the nurse include? "You will need to look to the side when you put the drops in your eye." "You should put the drops directly in the center of your eyeball." "You should cleanse your eye from the inner to the outer edge prior to putting in the drops." "You should avoid pressing on your tear duct after putting the drops in your eye." - ans"You should cleanse your eye from the inner to the outer edge prior to putting in the drops." A nurse is reinforcing teaching with a client who has hypertension and a prescription to measure her blood pressure daily. Which of the following client statements indicates an understanding of the teaching? a. "I will wait 15 minutes after drinking coffee to measure my blood pressure." b. "I will measure my blood pressure while my arm is elevated above my heart." c. "I should remove constrictive clothing prior to measuring my blood pressure." d. I should measure my blood pressure immediately after eating breakfast." - ans"I should remove constrictive clothing prior to measuring my blood pressure."
"I should avoid giving my baby a pacifier." "I will remove all stuffed animals from my baby's crib." "I will cover my baby with a light blanket when she is sleeping." - ans"I will remove all stuffed animals from my baby's crib." A nurse is reinforcing teaching with the partner of a client who is immobile. Which of the following instructions should the nurse give the partner about turning the client in bed? "Keep your feet close together." "Tighten your stomach muscles." "Straighten your knees." "Bend at your waist." - ans"Tighten your stomach muscles." A nurse is reinforcing teaching with the partner of a client who is immobile. Which of the following instructions should the nurse give the partner about turning the client in bed? "Keep your feet close together." "Tighten your stomach muscles." "Straighten your knees." "Bend at your waist." - ans"Tighten your stomach muscles." A nurse is working in a hospital overhears the following conversation between two other nurses on the elevator. Which of the following actions should the nurse take? inform the nurses that the neighbor's dog did not cause the wound tell the nurses that this conversation is not appropriate complete an incident report upon returning to the unit report the nurses' conversation to the client's provider - anstell the nurses that this conversation is not appropriate A nurse manager is reinforcing teaching with a group of newly licensed nurses about the disclosure of client
health information. A nurse can disclose health information without the client's written permission to which the following entities? An insurance agency offering a life insurance policy. A family member who requests the client's diagnosis. A physical therapist who is involved in the client's care. An employer completing a pre-employment screening. - ansAn employer completing a pre-employment screening. A nurse manager is reinforcing teaching with a group of newly licensed nurses about the disclosure of client health information. The nurse can disclose health information without the client's written permission to which of the following entities? an insurance agency offering a life insurance policy a family member who requests the client's diagnosis a physical therapist who is involved in the client's care an employer completing a pre-employment screening - ansa physical therapist who is involved in the client's care A nurse reinforcing teaching with a client who has pneumonia and a productive cough. Which of the following instructions should the nurse include in the teaching? "Your visitors should wear a protective gown." "You should receive a pneumonia vaccine every year." "You should stand 1 foot away from others when coughing." "You should cover your mouth with a tissue when you cough." - ans"You should cover your mouth with a tissue when you cough." A nurse working in a community clinic is talking with an older client who states that their life has no purpose. The nurse should identify that the client is in which of the following stages of Erikson's Theory of Psychosocial Development?
