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NURSING FUNDAMENTALS TEST
QUESTIONS EXAM 1-
The nurse is repairing to preform a dressing change for a client who has an open surgical wound on the abdomen. What is the most appropriate action by the nurse on finding that the seal on the sterile 4X dressing package is broken? - correct answer Discard them and obtain a new package The client is infected with fungus in the tines captious. What observation would the nurse note related to this diagnosis? - correct answer Lesions on the scalp A client has been prescribed antibiotics for a bacterial infection. What information is important for the nurse to tell the client? - correct answer Be sure to complete the entire course of treatment, even if symptoms are better A hospitalized client has been taking antibiotics for several days and develops C. diff. What symptom of this infection should the nurse be prepare to provide care for? - correct answer Diarrhea A client is suspected of having a UTI. What specimen does the nurse obtain to determine what bacteria is present as well as what antibiotic to use? - correct answer Urine for culture and sensitivity The nurse is preparing to irrigate a draining wound, and notes risk of splashing. What PPE should be donned? -gown -mask -particulate filter mask -shoe protectors -face Shiel/goggles - correct answer -gown -mask
-face shield/goggles What observation made by the charge nurse requires that the LPN receive further education? - correct answer The LPN recaps a needle after injecting a client The nurse is providing care tp a client when the client's IV becomes dislodged and blood splatters in the nurse's eye. After using the eyewash, what is the next appropriate action? - correct answer Report the incident to the supervisor What action by the CNA providing care to a client would require that the nurse intervene? - correct answer The CNA tales soiled linens from the bed and lets them fall on the floor The nurse is providing care to a group of clients. What priority action by the nurse will most help in preventing the spread of infection among this client group? - correct answer wash hands when entering and leaving client rooms Which of these clients needs to be placed in protective isolation? - correct answer - a client with severe burns that cover 50% of the body -a client about to receive a bone marrow transplant -a client receiving large doses of corticosteroids A client is suspected to be infected with MRSA in a sacral wound. What precautions should the nurse be sure are followed during care? - correct answer contact The nurse is preparing to administer medication to a client who is in isolation. What is an appropriate action for the nurse to take? - correct answer Unwrap all medications, and take them to their unit dose package in the room A client is placed on neutropenic precautions. What observation made by the nurse requires immediate intervention? - correct answer A volunteer puts on a gown, shoe and hair covers become bringing a vase of fresh flowers into the client's room
A provider states that they suspect a client to have "thrush" what signs might the nurse see that would be evidence for this diagnosis? - correct answer White "cottage cheese" looking patches in the client's mouth/throat Why are patients being treated for other resistant bacteria susceptible to C. diff infections? - correct answer Because their normal gut flora have been destroyed A client is suspect of having a chronic UTI. What test will best determine what organism is involved what what dug will best treat it? - correct answer Urine culture and sensitivity The nurse is preparing to do a wound irrigation and dressing change on a client with a draining wound. The wound infection is not from a resistant organism. What PPE should the nurse wear? - correct answer -clean gloves -gown -procedure mask -face shield The nurse was irrigating a client's catheter to remove blood cloths when the syringe become dislodged and urine splashed into the client's face. What should the nurse do after washing? - correct answer Report to supervisor A nursing student in the final term is working with a preceptor. What action by the student would require the preceptor to intervene? - correct answer The student recaps the needle after injecting the client to carry it across the room to the sharps container The nurse is helping supervise a new CNA. What action by the CNA would cause the nurse to intervene?
- correct answer The CNA assists the client with the bedpan, then places the bedpan on the bedside table while assisting the client back into a comfortable position. The home health nurse has several clients to see during the day. What is the most important action the nurse can take to prevent the spread of infection between these patients? - correct answer Throughly wash hands on entering and leaving each home
Which clients would be appropriate for protective (aka reverse/neutropenic) isolation? - correct answer -a client with 2nd-3rd degree burns over 50% of their body -a client on anti-rejection medications following an organ transplant -a client with severe congenital immune defect A client has a draining sacral wound which is suspected to be infected with MRSA. Which precautions should the nurse be sure are followed? - correct answer contact A client is suspected of having respiratory MRSA, what precautions should be followed? - correct answer droplet and contact The nurse is preparing to administer medication to a client in contact precautions. What is the proper procedure? - correct answer Open medications outside the room, then don gown and gloves and bring the med cup into the room along with the single dose packages A client is placed on neutropenic precautions. What observation made by the nurse would require immediate observation? - correct answer A volunteer starts to bring a fresh flower arrangement into the room Florence Nightingale believed that - correct answer Nature heals If you are providing health care, what might you always wear on the job? - correct answer A name tag A nurse has a license in Oregon and want to practice in Washington as well. Of what should the nurse be aware? - correct answer The nurse must obtain a WA license by endorsement Since hospital stays are becoming shorter and shorter, new nurses should be aware that - correct answer There will be proportionately more job openings in the community-based and long term care
A client was out enjoying the warm weather and stepped barefoot on some broken glass shards, getting a deep puncture wound on the sole of the foot. What is the nurse's priority question? - correct answer When was your last tetanus shot? A provider orders transmission precautions to be instituted for a client with a draining wound. What should the nurse do? - correct answer Place a sign on the door, and leave a card outside the room with gowns and gloves Which of the following precautions would the nurse observe as part of standard precautions? - correct answer Use PPE as needed to protect the blood and body fluids Observing standard precautions included which of the following actions? - correct answer -disposing of potentially infective material in a leak proof bag -protecting mucous membranes and not intact skin from blood and body fluid splashes -Washing hands frequently -safe disposal of sharps Which intervention is appropriate for a client under contact precautions? - correct answer Keep a dedicated set of vital signs equipment in the client's room A home health nurse finds a client canning food in the home. The client notes that they aren't too worried about making sure they process the food for the proper amount of time, just make sure it reaches boiling because it will kill all of the pathogens. What is the nurse's best response? - correct answer Some bacteria form spores that can survive boiling point and can live in sealed cans making bolulimim toxin Which patient assignment should an LPN question? - correct answer the patient with acute exacerbation of heart failure whose condition is rapidly changing Which of the following people can legally say they are a "nurse" on the job? - correct answer
A client has been admitted to a sub-acute hospital following heart surgery and to care for a pressure ulcer. Given the trend in inpatient stays, what should the nurse expect? - correct answer The nurse will have to teach the client's family how to care for the ulcer and arrange for home health follow up A client has end-stage kidney disease with a life expectancy of a few months. He has decided to give up dialysis and just wants to be as comfortable as possible while he dies. What care agency would be most appropriate for him? - correct answer hospice care in the home Which of the following is note true of an HMO? - correct answer A client can receive care anywhere Prospective payment means - correct answer The care facility will receive a set amount for the care of the client based on the diagnosis A client is poor and unsure whether she can pay for the surgery her child needs. The nurse would suggest a social work consult about signing the client up for what program? - correct answer medicaid A client who is undergoing chemo is wearing elastic bands on his wrists with flat beads that press onto the palmar side of the wrist, he says they help with nausea. The nurse recognizes that this is probably an example of what alternative healthcare modality? - correct answer Acupressure A long term care facility has a room set aside for "respite care" what kind of client does the nurse anticipate being admitted into that room? - correct answer A hospice client who is usually cared for at home but the family needs a break A client has low vision, what are some steps that the nurse can take to prevent falls? - correct answer -keep pathways clear of obstacles and tripping hazards -keep all furniture where the client is used to having it -mark the edges of steps with a contrasting color A client has difficulty caring for himself due to nerve damage in the hands. What department can provide strategies to increase the client's indolence? - correct answer OT
A parent brings a toddler into the clinic with a strong odor of cigarette smoke on the toddlers clothing. What information should the nurse discuss with the parent? - correct answer second hand smoke may cause numerous smoke related health problems A parent states that since the birth of a sibling, the older children is wetting the bed. How should the nurse respond to the parent? - correct answer This is referee to as regression and is a common defense mechanism The nurse is gathering data from a client in the home setting from a pressure wound. The nurse observes multiple areas of ecchymosis (bruising) in various stages of healing. The client states "they do their best to care for me, but get frustrated when I wet the bed." what is the priority nursing action? - correct answer Ensure the client's safety, and notify the adult protective services The nurse is assisting the client with removal of dentures prior to surgical procedure and the client asks why the dentures have to be removed. What is the best response by the nurse? - correct answer "there is a risk of aspiration or damage if the dentures are left in" The nurse is providing mouth care for an unconscious client. What position should the nurse place the client to prevent complications? - correct answer side-laying position A client requests the nurse to clean the earpieces of the hearing aid. What action should the nurse take to be sure it is cleaned properly? - correct answer clean the earpieces with Q-tips dipped in saline A client who has diabetes states to the nurse "I try to remove the calluses from my feet" what should the nurse be sure to discuss with the client to avoid complications? - correct answer Use oil or lotion to soften them only The nurse determines that the client requires a partial bath. In order to promote self-esteem? - correct answer encourage the client to do as much of the bath as they are able to do A student nurse approaches the instructor and states, "the stand nurse told me to witness the surgical consent after the surgeon signs it." What is the best response by the instructor? - correct answer "Students are not to serve as witnesses to legal papers. Lets explain this to the staff member so they can have it witnessed"
The nurse is caring for a client who has been confused and climbing out of bed. What action should the nurse take if the nurse must take care of another client and leave the room? - correct answer Don't leave the client alone and request that another staff member come and sit one on one with the client A nurse discovers that a neighbor is a client on the unit in which the nurse works, although the nurse is not assigned to that client. The nurse accesses the EMR to find out the client's diagnoses. What action may the nurse be liable for? - correct answer a HIPAA violation A staff nurse comes to work and accepts the assignment of clients. After a verbal altercation with the nurse manager about the assignment the nurse states "I quit" and leaves the facility. What action may the nurse manager take? - correct answer Report the nurse for abandonment of care A client is to be transferred from the acute care facility to a rehabilitation facility after suffering a stroke. The nurse is gathering papers to send to the accepting facility but is unsure of what to send. What is the best action by the nurse? - correct answer consult the charge nurse The nurse is gathering data from a client with loss of melanin production from age related changes. What observation made by the nurse correlates with this change? - correct answer white hair The nurse observes facial wrinkling on a 35 year old client. What questions should the nurse ask pertaining to this finding? - correct answer -do you smoke -do you drink alcohol -do you spend a lot of time in the sun -did either of your parents wrinkle prematurely A client lacks the DNA repair enzyme that helps reverse UV damage. What should the nurse be sure to include with information related to this lack of enzyme? - correct answer closely check the skin for new or changes in moles
-within the bounds of safety, take the client's wishes into account When a client with a diagnosis of bronchial asthma and a history of numerous sensitivities reports that the room smells unpleasant, the nurse attempts to solve the problem by spraying an air freshener. Within minutes, the client begins experiencing bronchial spasms and dyspnea. What legal label could describe the nurse's actions? - correct answer Negligence What information about the safety of smokeless tobacco should the nurse give a client who uses this form of tobacco extensively? - correct answer It is as dangerous as regular tobacco The nurse is reviewing the list of medical diagnoses of a client to care plan as needed. Which diagnoses has the highest potential to result in long-term impairment for the client? - correct answer rheumatoid arthritis A client has an Infection ion of the left eye and is producing drainage. What is the correct procedure and why? - correct answer Use a separate cloth for each eye to avoid spreading infection A nurse is caring for an unresponsive client. Which therapeutic nursing intervention is appropriate when providing mouth care to this client? - correct answer Have suction available if ordered When providing information to a client with a potential skeletal injury the nurse should be sure to provide information about what test that is most commonly used to determine the state of the skeletal system? - correct answer x-ray A client has potentially soft-tissue injury and may need an MRI. What question should you be sure to ask? - correct answer Do you have any plates, rods, or any other metallic implants? The nurse is educating a patient about managing his gout. What should the nurse say causes the pain in gout? - correct answer Gout is caused by uric acid crystals building up in a joint A nurse is caring for a client with systemic lupus errythematosus. Besides subcutaneous tissues, the nurse needs to be prepared to provide care for possible dysfunction of what other body tissues? -
correct answer Anywhere there is college in the body, including joints, blood vessels, heart, lungs, and kidneys A client questions their diagnosis of rheumatoid arthritis stating that their too young and haven't "mistreated" their joints. What is the best answer for the nurse to give? - correct answer Rheumatoid arthritis is an autoimmune disease, it can affect anyone even children A nurse is participating in a well-child visit for a year old child of vegan parents who is being weaned to solid foods. What information should the nurse give to the parents? - correct answer Not all plant based milks provide adequate calcium. Be sure to check the nutrition label to make sure your child is getting enough Which of the following assessment date from a client with joint immobilization device should immediately report to the provider? - correct answer -capillary refill time > seconds distal to the device -client reports "pins and needles" sensation distal to the device Which information should a nurse provide to an aging client who wishes to avoid or delay osteoporosis?
- correct answer Be sure to eat a nutritionally complete diet and get weight bearing exercise such as walking daily The. nurse practice act in each state is an example of what kind of law? - correct answer salutatory In order to protect themselves form lawsuits nurses should: - correct answer -listen and document their client's reported symptoms -follow their facilities policies and procedures Which of the following are true regarding macitence of professional boundaries? - correct answer -the responsibility for maintaining the boundaries of the relationship rest on the nurse -there is an inequality of power in the nurse/client relationship Durable healthcare power of attorney - correct answer A person selected to make care decisions on behalf of an individual who is incapacitated
Which of these clients is the priority for the ED nurse? - correct answer The 55 year old with acute SOB Which of the following is true of a misdemeanor? - correct answer Can be cause for revocation of licensure According to WHO, health is - correct answer A complete state of well being, not just an absence of disease An example of a community meeting a safety and security need would be - correct answer establishing an ambulance and firefighting service All of the following are true of preventative health services except: - correct answer they are focused solely on preventing the disease Which of the following are health care concerns for newborns? - correct answer - low birth weights -congenital illnesses -SIDS Which of the following will not move someone most quickly toward the illness side of the wellness- illness continuum? - correct answer Acute illness Which of the following is NOT a good principle of good body mechanics - correct answer tighten your back muscles to lift Which of the following is true of caring for very curly hair - correct answer Scarves or caps are often worn at night Which of the following is true of bathing a client - correct answer During a bed bath be sure to inspect the skin as each area is being washed
What is true of bones? - correct answer Bones are constantly being broken down and rebuilt by actions of osteoclasts and osteoblast cells In which situation should the nurse identify that the care plan needs to be revised? - correct answer The client is losing weight and eating only a small amount of food The charge. nurse requests that the nurse provide oral hygiene every 2 hours for a client with a nasogastric tube. What part of the nursing process is being carried out? - correct answer Implementation A client is being treated for an infected sacral decubitus ulcer. The nurse has performed prescribed wound care twice a day for 5 days. What part of the nursing process should be preformed next? - correct answer Evaluation of the care provided After data collection what step of the nursing process occurs - correct answer The development of the nursing diagnosis The nurse is caring for a client who has been involved in a motor vehicle crash. Which of the following signs or symptoms displayed by the client has the highest priority? - correct answer The client having difficulty breathing Which of the following data collected during a client assessment is an olfactory observation - correct answer The client's breath has a fruity odor The nurse is preparing to collect admission data on a hospitalized client. What methods will the nurse use to obtain the necessary data? - correct answer -interview the client -preform a physical exam -observe the client The nurse is interviewing a client with a rash all over the face arms and trunk. What question to be asked by the nurse takes priority? - correct answer Are you allergic to any foods, medicines, or topical creams
Langerhans cells - correct answer participate in the immune and allergy responce Melanocyte - correct answer Creates substance that protects skin from the sun A nurse is caring for a client who has lost 30% of his skin due to trauma. The nurse knows that the compromised integumentary system has the following complications for the client: - correct answer -client will need to have fluid balance carefully monitored -Client may need vitamin D supplementation -The client will need to be protected against infection -Extra care will need to be taken to preserve noremothermia A nursing student wonders why he gets all sweaty during a nursing exam. What should his friends tell him? - correct answer Apocrine sweat glands are triggered to increase secretions during times of stress A nurse is caring for a hypothermic patient and is trying to precent the client from losing heat in any way. What is a way for the nurse to prevent heat loss by conduction? - correct answer Put insulating fabric between the client and the surface under them A nurse wants to assess the client for signs and symptoms of heat loss. What is an early sign that the client's body is trying to retain more heat that usual? - correct answer The hairs on the clients exposed skin will be standing upright A nurse is asked by a young client how to keep their skin looking young longer. What can the nurse recommend? - correct answer -eat a balanced diet, drink lots of fluids -Protect the skin from the sun -avoid smoking An older client is in for an annual checkup is concerned because their skin has sone brown spots and some areas have lost their usual color. What teaching can the nurse provide the client? - correct answer These changes in pigmentation are a normal part of aging
A client has itching, red areas on the scalp. What would glowing white areas on the scalp seen under a Wood's lamp indicate? - correct answer The client probably has a fungal infection of the scalp Macule - correct answer A flat, dark colored lesion Vesicle - correct answer a raised lesion filled with serious fluid Pustule - correct answer a raised lesion filled with white cells, bacterial, and cellular debris Fissure - correct answer a crack in the skin A client has widespread itching of the skin. The doctor has diagnosed an allergic reaction and given a prescription for anti-anxiety medication. In addition to drug teaching, what suggestions can the nurse give to help deal with the itching? - correct answer -wear clothes in natural fabrics that breathe -use bath oil or soothing starch solution in cooler water for bathing -avoid scented skin products and laundry detergent A nurse is caring for a child with eczema. what are appropriate measures to take? - correct answer -keep the child's fingernails cut short -keep the child's skin moist -try to identify dietary triggers for the reaction The client has burns over 20% of his body. They are mostly blisters and areas where the dermis is visible. What degree of burns are they? - correct answer second What is the priority consideration of a nurse caring for a client in the resuscitative phase of burn treatment - correct answer preservation of airway and circulatory volume
