RN Fundamentals Final Questions & Answers

congruence on the part of the nurse implies: - ANSWERSusing communication tools in a genuine and spontaneous manner 1 day pot-op abdominal surgery. what is the first action the nurse should take after discovering that the client's wound has eviscerated? - ANSWERScover the incision with a moist sterile dressing admitted to the hospital after being on bed rest at home. the client has been incontinent and smells strongly of urine. his spouse states that she is sorry and embarrassed about the unpleasent smell: - ANSWERSit must be difficult to care for someone who is confined to a bed orders a cleansing enema for a client having bowel surgery. which nursing intervention is appropriate: - ANSWERSposition client on side ambulating in hallway with bare feet. priority nursing action is: - ANSWERSget the client's slippers and have them put them on mouth care to client with total care: - ANSWERSturn the client on his side before begining while preparing for discharge the nurse teaches proper position for postural drainage. the nurse knows that to achieve success in his teaching program, the info about the client is most important: - ANSWERSclient's goal concerning his ability to be self-sufficient taking several medications to treat congestive heart failure and RA arrives that the clinic reporting fatigue, anorexia, and nausea. assessment a priority? - ANSWERShave you been taking your medication as prescribed client who has type 1 diabetes is scheduled for an appendectomy. the client has been NPO since midnight. there are no-preoperative orders for daily insulin dose. which intervention is appropriate: - ANSWERScall the provider to request an insulin insert a NG tube. the nurse understands that an improper use of the NG tube would be for: - ANSWERSmaintaining NPO status prescribed restraints for a client who is agitated. the nurse would put the client at risk for: - ANSWERStying the restraint with a knot that cannot be easily undone reports SOB requests the help in changing positions. in addition to re-positioning the client, the nurse's highest priority should be: - ANSWERSobserve, rate, depth, and character of the client's respirations when transcribing orders for a client admitted with an exacerbation of SLE a new nurse notes that the provider prescribed med that in unfamiliar. the nurse should: - ANSWERSconsult the medication reference book following an emergency splenectomy, a 17 year old is admitted to the nursing unit from PACU. the client reports severe abdomen pain, and the client's parents are asking to see their child. the nurse's first action should be: - ANSWERScomplete a physical assessment including post-op vitals nurse is planning ROM for a client. the nurse understands that active ROM is performed before passive ROM because: - ANSWERSactive ROM is used to determine limitation of movement nurse enters room and finds client in respiratory arrest, priority: - ANSWERSestablish an open airway client is prescribed hypothermia blanket. when caring for the client: - ANSWERSplace a layer of cloth between the client and blanket preparing client with a compression injury of the right leg for surgery. after administering the pre-op bezodiazepidine, (ATIVAN) as prescribed, the nurse determines that the medication was effective when the client states: - ANSWERSi feel very sleepy client is being prepared for surgery after pre-op medication. the nurse makes sure that: - ANSWERSconsent from has been signed strict bed rest client. when entering room, nurse notices flames in waste basket. the nurses priority action is to: - ANSWERSpull the client out into the hall in bed misconception when: - ANSWERSorgan donation is strictly forbidden by the Baptist Church high fever, chills, and dehydration, the nurse knows that which lab test will not help the provider confirm infection: - ANSWERSglucose PACU following splenectomy. abdominal dressing is dry and intact and IV fluids are infusing at 125 mL/hr. nursing priority: - ANSWERSmaintaining patent airway client suddenly coughs a few times then attempts to cough and makes a whistling sounds on inhalation. choking. heimlich maneuver: - ANSWERSboth arms around, fist n between bottom of sternum and navel 16 year old client who has had multiple injuries included a brain contusion as a result of a moto crash. has been combative and impulsive and has pushed the nurse away and climbed over the side rails. his parents tell the nurse., "this is not like our son at all". nurse intervention will best ensure the safety of the client? - ANSWERSassign a staff member to sit with the client around the clock two days post op following bowel resecion, a client reports gas pains in the preiumbilical area. the nurse notes abdominal distention and revises the clients care plan based on the knowledge that post op gas pains develop as a result of: - ANSWERSimpaired peristalsis if the intestines a post op client's knee dressing becomes completely saturated with blood 1 hr after the transfer to the clienical unit. appropriate to: - ANSWERSapply direct pressure to the operative site caring for 5 year old child returning from the surgical suite following suite following an exploratory laparotomy and removal of a ruptured appendix. when writing the child's nursing car plan, the nurse's priority: - ANSWERShaving the child turn and cough and breathe deeply every 2 hours a nurse is teaching a client recovring from a CVA how to dress. the client has residual hemipelgia, so the nurse instructs the client to do which of the following: - ANSWERSslide your weaker arm through its sleeve first no way! you are not putting that hose down my throat. get away from me. which of the following statements is an appropriate nursing response? - ANSWERSi can see that this is upsetting you client is being discharged to home with oxygen therapy via nasal cannula. which instruction should the nurse give to the client and family. - ANSWERSwear clothing to avoid static electricity right handed client is admitted with a fractured right arm and contusions to the left wrist. which intervention should the nurse use: - ANSWERSoffer small bites of food finished teaching a client with diverticulosis about appropriate dietary choices. which selection by a client on indicates to understanding? - ANSWERSfresh green beans instead of canned for lunch demonstrates safe principles of administering a routine immunization to an infant? - ANSWERSinject the vaccine into the vastus lateralis muscle 2 days post op an appendectomy. changing the linens on the client's bed, the nurse notes drainage from an infected wound has soiled the bed sheet. action should be: - ANSWERScarefully place the soiled sheet in a moisture-resistant plastic laundry bag