Download Nursing Fundamentals: Transfer Procedures, Spiritual Distress, Assessments, and Infusions and more Exams Nursing in PDF only on Docsity!
Fundamentals Practice Exam. The healthcare provider prescribes morphine sulfate 4mg IM STAT. Morphine comes in 8 mg per ml. How many ml should the nurse administer? 0.5 ml. A hospitalized male client is receiving nasogastric tube feedings via a small-bore tube and a continuous pump infusion. He reports that he had a bad bout of severe coughing a few minutes ago, but feels fine now. What action is best for the nurse to take? After clearing the tube with 30 ml of air, check the pH of fluid withdrawn from the tube. A client is in the radiology department at 0900 when the prescription levofloxacin (Levaquin) 500 mg IV q24h is scheduled to be administered. The client returns to the unit at 1300. What is the best intervention for the nurse to implement? Give the missed dose at 1300 and change the schedule to administer daily at 1300. A client is to receive 10 mEq of KCl diluted in 250 ml of normal saline over 4 hours. At what rate should the nurse set the client's intravenous infusion pump? 63 ml/hour. The UAPs working on a chronic neuro unit ask the nurse to help them determine the safest way to transfer an elderly client with left-sided weakness from the bed to the chair. What method describes the correct transfer procedure for this client? Move the chair parallel to the right side of the bed, and stand the client on the right foot. On admission, a client presents a signed living will that includes a Do Not Resuscitate (DNR) prescription. When the client stops breathing, the nurse performs cardiopulmonary resuscitation (CPR) and successfully revives the client. What legal issues could be brought against the nurse? ) Battery Civil laws protect individual rights and include intentional torts, such as assault (an intentional threat to engage in harmful contact with another) or battery (unwanted touching). Performing any procedure against the client's wishes can potentially poise a legal issue, such as battery (B), even if the procedure is of questionable benefit to the client. (A, C, and D) are not examples against the client's request A resident in a skilled nursing facility for short-term rehabilitation after a hip replacement tells the nurse, "I don't want any more blood taken for those useless tests." Which narrative documentation should the nurse enter in the client's medical record? Healthcare provider notified of client's refusal to have blood specimens collected for testing. At the beginning of the shift, the nurse assesses a client who is admitted from the post- anesthesia care unit (PACU). When should the nurse document the client's findings?
Immediately after the assessments are completed. An Arab-American woman, who is a devout traditional Muslim, lives with her married son's family, which includes several adult children and their children. What is the best plan to obtain consent for surgery for this client? D) Tell the surgeon that the son will decide after explanation of the proposed surgery is provided. Traditional Muslim women live in a patriarchal family where decisions are made by men. Most likely, the son will make the decision for his mother, so Which response by a client with a nursing diagnosis of Spiritual distress, indicates to the nurse that a desired outcome measure has been met? Accepts that punishment from God is not related to illness Acceptance that she is not being punished by God indicates a desired outcome During shift change report, the nurse receives report that a client has abnormal heart sounds. Which placement of the stethoscope should the nurse use to hear the client's heart sounds? Use the stethoscope bell over the valvular areas of the anterior chest Abnormal heart sounds are best heard with the bell of the stethoscope, which picks up lower- pitched sounds, that is placed at points on the anterior chest A nurse is preparing to give medications through a nasogastric feeding tube. Which nursing action should prevent complications during administration? A) Mix each medication individually Medications should be mixed separately (A) to prevent clumping. The nurse is performing nasotracheal suctioning. After suctioning the client's trachea for fifteen seconds, large amounts of thick yellow secretions return. What action should the nurse implement next? Re-oxygenate the client before attempting to suction again. When evaluating a client's plan of care, the nurse determines that a desired outcome was not achieved. Which action will the nurse implement first? Note which actions were not implemented.
Q & AS) BEST EXAM SOLUTION SATISFACTION
GUARANTEED SUCCESS LATEST UPDATE 2022/
GRADED A+
should the nurse take? Infuse 10 percent dextrose and water at 54 ml/hr. During the admission interview, which technique is most efficient for the nurse to use when obtaining information about signs and symptoms of a client's primary health problem? Closed-ended questions Lay descriptors of health problems can be vague and nonspecific. To efficiently obtain specific information, the nurse should use closed-ended questions (C) that focus on common signs and symptoms about a client's health problem An older client who is a resident in a long term care facility has been bedridden for a week. Which finding should the nurse identify as a client risk factor for pressure ulcers? Rashes in the axillary, groin, and skin fold regions Immobility, constant contact with bed clothing, and excessive heat and moisture in areas where air flow is limited contributes to bacterial and fungal growth, which increases the risk for rashes A client who has been NPO for 3 days is receiving an infusion of D5W 0.45 normal saline (NS) with potassium chloride (KCl) 20 mEq at 83 ml/hour. The client's eight-hour urine output is 400 ml, blood urea nitrogen (BUN) is 15 mg/dl, lungs are clear bilaterally, serum glucose is 120 mg/dl, and the serum potassium is 3.7 mEq/L. Which action is most important for the nurse to implement? Document in the medical record that these normal findings are expected outcomes
NURSING251 FUNDAMENTALS PRACTICE EXAM. (
Q & AS) BEST EXAM SOLUTION SATISFACTION
GUARANTEED SUCCESS LATEST UPDATE 2022/
Q & AS) BEST EXAM SOLUTION SATISFACTION
GUARANTEED SUCCESS LATEST UPDATE 2022/
GRADED A+
The results are all within normal range.(C) No changes are needed. What action should the nurse implement when accessing an implanted infusion port for a client who receives long term IV medications? Insert a Huber-point needle into the port An implanted infusion port needs to be accessed using a Huber-point needle (B) (non- coring) to be prevent damage to the self-sealing septum of the port. During the daily nursing assessment, a client begins to cry and states that the majority of family and friends have stopped calling and visiting. What action should the nurse take? Listen and show interest as the client expresses these feelings When a client begins to cry and express feelings, a therapeutic nursing intervention is to listen and show interest as the client expresses feelings The nurse plans to obtain health assessment information from a primary source. Which option is a primary source for the completion of the health assessment? Client A primary source of information for a health assessment is the client (A). (B, C, and D) are considered secondary sources about the client's health history, but other details, such as subjective data, can only be provided directly from the client. The nurse is using a genogram while conducting a client's health assessment and past medical history. What information should the genogram provide? Genetic and familial health disorders A genogram that is used during the health assessment process identifies genetic and
NURSING251 FUNDAMENTALS PRACTICE EXAM. (
Q & AS) BEST EXAM SOLUTION SATISFACTION
GUARANTEED SUCCESS LATEST UPDATE 2022/
Q & AS) BEST EXAM SOLUTION SATISFACTION
GUARANTEED SUCCESS LATEST UPDATE 2022/
GRADED A+
exercises to his contracted shoulder, the nurse observes that she is holding his arm above and below the elbow. What nursing action should the nurse implement? Acknowledge that she is supporting the arm correctly. An elderly male client who is unresponsive following a cerebral vascular accident (CVA) is receiving bolus enteral feedings though a gastrostomy tube. What is the best client position for administration of the bolus tube feedings? Fowler's. An adult male client with a history of hypertension tells the nurse that he is tired of taking antihypertensive medications and is going to try spiritual meditation instead. What should be the nurse's first response? It is important that you continue your medication while learning to meditate. A client is to receive cimetidine (Tagamet) 300 mg q6h IVPB. The preparation arrives from the pharmacy diluted in 50 ml of 0.9% NaCl. The nurse plans to administer the IVPB dose over 20 minutes. For how many ml/hr should the infusion pump be set to deliver the secondary infusion? 150 The nurse is completing a mental assessment for a client who is demonstrating slow thought processes, personality changes, and emotional lability. Which area of the brain controls these neuro-cognitive functions? Frontal lobe A client is receiving a cephalosporin antibiotic IV and complains of pain and irritation at the infusion site. The nurse observes erythema, swelling, and a red streak along the vessel above the IV access site. Which action should the nurse take at this time?
NURSING251 FUNDAMENTALS PRACTICE EXAM. (
Q & AS) BEST EXAM SOLUTION SATISFACTION
GUARANTEED SUCCESS LATEST UPDATE 2022/
Q & AS) BEST EXAM SOLUTION SATISFACTION
GUARANTEED SUCCESS LATEST UPDATE 2022/
GRADED A+
Initiate an alternate site for the IV infusion of the medication. A female client asks the nurse to find someone who can translate into her native language her concerns about a treatment. Which action should the nurse take? Request and document the name of the certified translator.
NURSING251 FUNDAMENTALS PRACTICE EXAM. (
Q & AS) BEST EXAM SOLUTION SATISFACTION
GUARANTEED SUCCESS LATEST UPDATE 2022/
Q & AS) BEST EXAM SOLUTION SATISFACTION
GUARANTEED SUCCESS LATEST UPDATE 2022/
GRADED A+
Which assessment data would provide the most accurate determination of proper placement of a nasogastric tube? Examining a chest x-ray obtained after the tubing was inserted. The nurse mixes 50 mg of Nipride in 250 ml of D5W and plans to administer the solution at a rate of 5 mcg/kg/min to a client weighing 182 pounds. Using a drip factor of 60 gtt/ml, how many drops per minute should the client receive? 124 gtt/min. At the time of the first dressing change, the client refuses to look at her mastectomy incision. The nurse tells the client that the incision is healing well, but the client refuses to talk about it. What would be an appropriate response to this client's silence? It is OK if you don't want to talk about your surgery. I will be available when you are ready. Examination of a client complaining of itching on his right arm reveals a rash made up of multiple flat areas of redness ranging from pinpoint to 0.5 cm in diameter. How should the nurse record this finding? Localized red rash comprised of flat areas, pinpoint to 0.5 cm in diameter. The nurse is teaching a client with numerous allergies how to avoid allergens. Which instruction should be included in this teaching plan? Avoid any types of sprays, powders, and perfumes. A client with pneumonia has a decrease in oxygen saturation from 94% to 88% while ambulating. Based on these findings, which intervention should the nurse implement first? Assist the ambulating client back to the bed.
NURSING251 FUNDAMENTALS PRACTICE EXAM. (
Q & AS) BEST EXAM SOLUTION SATISFACTION
GUARANTEED SUCCESS LATEST UPDATE 2022/
Q & AS) BEST EXAM SOLUTION SATISFACTION
GUARANTEED SUCCESS LATEST UPDATE 2022/
GRADED A+
The nurse is teaching a client proper use of an inhaler. When should the client administer the inhaler-delivered medication to demonstrate correct use of the inhaler? During the inhalation The nurse is instructing a client with high cholesterol about diet and life style modification. What comment from the client indicates that the teaching has been effective? I will limit my intake of beef to 4 ounces per week. When assessing a client with wrist restraints, the nurse observes that the fingers on the right hand are blue. What action should the nurse implement first? Loosen the right wrist restraint. A male client being discharged with a prescription for the bronchodilator theophylline tells the nurse that he understands he is to take three doses of the medication each day. Since, at the time of discharge, timed-release capsules are not available, which dosing schedule should the nurse advise the client to follow? 8 a.m., 4 p.m., and midnight. An IV infusion terbutaline sulfate 5 mg in 500 ml of D5W, is infusing at a rate of 30 mcg/min prescribed for a client in premature labor. How many ml/hr should the nurse set the infusion pump? 180 An elderly client who requires frequent monitoring fell and fractured a hip. Which nurse is at greatest risk for a malpractice judgment? The nurse who transferred the client to the chair when the fall occurred. The nurse witnesses the signature of a client who has signed an informed consent. Which statement best explains this nursing responsibility?
NURSING251 FUNDAMENTALS PRACTICE EXAM. (
Q & AS) BEST EXAM SOLUTION SATISFACTION
GUARANTEED SUCCESS LATEST UPDATE 2022/
Q & AS) BEST EXAM SOLUTION SATISFACTION
GUARANTEED SUCCESS LATEST UPDATE 2022/
GRADED A+
A client who is 5' 5" tall and weighs 200 pounds is scheduled for surgery the next day. What question is most important for the nurse to include during the preoperative assessment? What vitamin and mineral supplements do you take? An elderly client with a fractured left hip is on strict bedrest. Which nursing measure is essential to the client's nursing care? Gently lift the client when moving into a desired position. During a physical assessment, a female client begins to cry. Which action is best for the nurse to take? Acknowledge the client's distress and tell her it is all right to cry. Which action is most important for the nurse to implement when donning sterile gloves? Keep gloved hands above the elbows. The nurse is evaluating client learning about a low-sodium diet. Selection of which meal would indicate to the nurse that this client understands the dietary restrictions? Skim milk, turkey salad, roll, and vanilla ice cream. An unlicensed assistive personnel (UAP) places a client in a left lateral position prior to administering a soap suds enema. Which instruction should the nurse provide the UAP? Reposition in a Sim's position with the client's weight on the anterior ilium. An African-American grandmother tells the nurse that her 4-year-old grandson is suffering with "miseries." Based on this statement, which focused assessment should the nurse conduct? Inquire about the source and type of pain
NURSING251 FUNDAMENTALS PRACTICE EXAM. (
Q & AS) BEST EXAM SOLUTION SATISFACTION
GUARANTEED SUCCESS LATEST UPDATE 2022/
Q & AS) BEST EXAM SOLUTION SATISFACTION
GUARANTEED SUCCESS LATEST UPDATE 2022/
GRADED A+
A postoperative client will need to perform daily dressing changes after discharge. Which outcome statement best demonstrates the client's readiness to manage his wound care after discharge? The client demonstrates the wound care procedure correctly. The nurse assigns a UAP to obtain vital signs from a very anxious client. What instructions should the nurse give the UAP? Report the results of the vital signs to the nurse. The nurse observes an unlicensed assistive personnel (UAP) taking a client's blood pressure with a cuff that is too small, but the blood pressure reading obtained is within the client's usual range. What action is most important for the nurse to implement? Reassess the client's blood pressure using a larger cuff. The healthcare provider prescribes the diuretic metolazone (Zaroxolyn) 7.5 mg PO. Zaroxolyn is available in 5 mg tablets. How much should the nurse plan to 1½ tablets A client with acute hemorrhagic anemia is to receive four units of packed RBCs (red blood cells) as rapidly as possible. Which intervention is most important for the nurse to implement? Ensure the accuracy of the blood type match. The nurse notices that the Hispanic parents of a toddler who returns from surgery offer the child only the broth that comes on the clear liquid tray. Other liquids, including gelatin, popsicles, and juices, remain untouched. What explanation is most appropriate for this behavior? Hot remedies restore balance after surgery, which is considered a "cold" condition.
NURSING251 FUNDAMENTALS PRACTICE EXAM. (
Q & AS) BEST EXAM SOLUTION SATISFACTION
GUARANTEED SUCCESS LATEST UPDATE 2022/
Q & AS) BEST EXAM SOLUTION SATISFACTION
GUARANTEED SUCCESS LATEST UPDATE 2022/
GRADED A+
these practices? Many complimentary healing practices can be used in conjunction with conventional practices. An elderly male client who suffered a cerebral vascular accident is receiving tube feedings via a gastrostomy tube. The nurse knows that the best position for this client during administration of the feedings is Fowler's. Heparin 20,000 units in 500 ml D5W at 50 ml/hour has been infusing for 5½ hours. How much heparin has the client received? 11,000 units 20 000 units /500 ml= 40 40*50= Which snack food is best for the nurse to provide a client with myasthenia gravis who is at risk for altered nutritional status? Chocolate pudding.
NURSING251 FUNDAMENTALS PRACTICE EXAM. (
Q & AS) BEST EXAM SOLUTION SATISFACTION
GUARANTEED SUCCESS LATEST UPDATE 2022/
