Exam 2: NSG3130 / NSG 3130 (Latest 2026 / 2027) Fundamental Concepts & Skills for Nursing Practice II | 100% Correct Questions & Answers - Galen

Exam 2: NSG3130 / NSG 3130 (Latest 2026 / 2027) Fundamental Concepts & Skills for Nursing Practice II | 100% Correct Questions & Answers - Galen Question: An occupational health nurse is going to provide a workshop to employees on basic body mechanics. In planning the presentation and preparing the materials. What information would be most helpful for the nurse to obtain in advance of the presentation? A. Specific ages of all the employees. B. Names of the employees. C. Names of the managers. D. Number of participants. D. Number of participants. Which of the following strategies is the most appropriate for teaching a toddler about a hospital procedure? A. Discussion. B. Pictures. C. Role playing. D. Independent learning. B. Pictures. The nurse assesses the patients readiness to learn wound care. What is the most important factor for the nurse to determine first? A. Intelligence level of the patient. B. Willingness to learn the technique. C. Financial resources available to the patient. D. Support from the patient's family. B. Willingness to learn the technique. Which one of the following examples is an evaluation of a psychomotor skill? A. Patient is able to discuss side effects of medications. B. Patient maintains eye contact with nurse. C. Patient has planned menu within therapeutic diet. D. Patient uses walker correctly. D. Patient uses walker correctly. When teaching an older adult patient, the nurse should incorporate which teaching strategy into the plan? A. Keep the teaching sessions short. B. Teach in the later evening. C. Include as many concepts as possible. D. Focus on teaching the family members. A. Keep the teaching sessions shorts. Which of the following statements by the patient indicates that he may not be ready to learn at this time? A. "I'll call and make an appointment with the physical therapist for follow up on the exercises". B. "I want to know more about the side effects of the medications". C. "There's no sense in talking about this now. I don't feel very well". D. "Let me know if I am doing this dressing the right way". C. "Theres no sense in talking about this now. I don't feel very well". Which one of the following examples is an evaluation of cognitive learning? The patient: A. Explains the use of the incentive spirometer. B. Looks at the site of the amputation. C. Uses the crutches to go up and down the stairs. D. Completes hygienic care independent. A. Explains the use of the incentive spirometer. In the affective domain of learning, the patient exhibits the ability to do which of the following? A. Perform self catheterization. B. Provide information on dialysis. C. Return demonstrate blood pressure measurement. D. Verbalize feelings about how to manage arthritis pain. D. Verbalize feelings about how to manage arthritis pain. To promote a patient's cognitive learning, the nurse decides to use which teaching strategy? A. Demonstrating a procedure. B. Modeling appropriate ways to interact. C. Showing a DVD about the disease process. D. Discussing personal thoughts about surgery. C. Showing a DVD about the disease process. The nurse uses the vark tool to determine the patient's learning style. Which learning is being assessed by the "R" component? A. Ability to speak about the information. B. Use of reading and writing. C. Movement and skill performance. D. Perception based on hearing the material. B. Use of reading and writing. A patient has been on bedrest for a prolonged period. To specifically promote the use of isotonic exercise, the nurse will instruct the patient to: A. Turn side to side in bed. B. Perform pelvic floor exercises. C. Repeatedly tighten the thigh muscle. D. Use a trapeze to lift and hold the upper body off the bed. A. Turn side to side in bed. An average size male patient has right-sided hemiparesis, requiring minimal assistance with ambulation. The nurse helps this patient walk by standing at his: A. Left side and holding his arm. B. Left side and holding one arm around his waist. C. Right side and holding his arm. D. Right side and holding the gait belt at the patient's back. D. Right side and holding the gait belt at the patient's back. The nurse is working with a patient who has left-sided weakness. after instruction, the nurse observes the patient ambulate in order to evaluate the use of the cane. Which action indicates that the patient knows how to use a cane properly? A. The patient keeps the cane on the left side. B. Two points of support are kept on the floor at all times. C. There is a slight lean to the right when the patient is walking. D. After advancing the cane, the patient moves the right leg forward. B. Two points of support are kept on the floor at all times. A patient with a fractured left femur has been using crutches for the past 4 weeks. The physician tells the patient to begin putting weight on the left foot when walking. Which of the following gaits should the patient be taught to use? A. Two point. B. Three point. C. Four point. D. Swing through. C. Four point. While ambulating in the hallway of the hospital. The patient complains of extreme dizziness. The nurse, alert to a syncopal episode, should first: A. Support the patient and walk quickly back to the room. B. Lean the patient against the wall until the episode passes. C. Lower the patient gently to the floor. D. Go for help. C. Lower the patient gently to the floor. A patient is admitted to the medical unit after a cerebral vascular accident. There is evidence of left-sided hemiparesis, and the nurse will be following up on range of motion and other exercises performed in physical therapy. The nurse correctly teaches the patient and family members which one of the following principles of range of motion of exercises? A. Move the joints quickly. B. Work from the lower to upper body. C. Flex the joint to the point of resistance. D. Provide support above and below joints. D. Provide support above and below joints. Nurses need to implement appropriate body mechanics to decrease the chance of injury to themselves and patients. Which principle of the body mechanics should the nurse incorporate into patient care? A. Flex the knees and keep the feet wide apart. B. Assume the position far enough away from the patient. C. Twist the body in the direction of movement. D. Use the strong back muscles for lifting or moving. A. Flex the knees and keep the feet wide apart. After an assessment of a patient, the nurse identifies the nursing diagnosis in tolerance to activity with the supporting evidence of increased weight gait and inactivity. The physician wants the patient to improve her endurance and increase activity. Which of the following is an outcome identified for the patient? A. Resting heart rate will be 90 to 100/min B. Blood pressure will be maintained between 140/80 and 160/90 mm Hg. C. Exercise will be performed three times per day over the next two weeks. D. Accommodation will be made for excess weight and fatigue. C. Exercise will be performed three times per day over the next two weeks. A patient has been on prolonged bed rest, and the nurse is observing for signs associated with immobility. In assessment of the patient. The nurse is alert to: A. Increase blood pressure. B. Decreased heart rate. C. Increased urinary output. D. Decreased peristalsis. D. Decreased peristalsis. 2 nurses are standing on opposite sides of the bed to move the patient up in bed with a draw sheet. Where should the nurses be standing in relation to the patient's body as they prepare for the move? A. Even with the thorax. B. Even with the shoulders. C. Even with the hips. D. Even with the knees. B. Even with the shoulders. A patient is leaving for surgery and, because of preoperative sedation, needs complete assistance to transfer from the bed to the stretcher. Which of the following should the nurse do first? A. Elevate the head of the bed. B. Obtain more assistance for the move. C. Place the patient in the prone position. D. Assess the situation for any potentially unsafe complications. D. Assess the situation for any potentially unsafe complications. A patient has sequential compression stockings in place. Which of the following indicates that they are being implemented correctly? A. The ankle pressure is set to 40mmHg. B. Stockings are removed every hour during application. C. There is no space between the sleeve and the leg when the sleeve is not inflated. D. If there is an order for only one leg, the other sleeve is disconnected from the machine. A. The ankle pressure is set to 40mmHg. The nurse assesses that the patient has right sided hemiparesis after a stroke. This individual most likely had ischemia to the: A. Right side of the brain. B. Left side of the brain. C. Cerebellum. D. Medulla oblongata. B. Left side of the brain. An immobilized patient is suspected of having atelectasis. This is assessed by the nurse, on auscultation as: A. Harsh crackles. B. Wheezing on inspiration. C. Diminished breath sounds. D. Bronchovesicular whooshing C. Diminished breath sounds. The best approach for the nurse to use to assess the presence of DVT in an immobilized patient is to: A. Measure the calf and thigh in diameters. B. Attempt to elicit the homan sign. C. Palpate the temperature of the feet. D. Observe for a loss of hair and skin turgor in the lower legs. A. Measure the calf and thigh in diameters. The patient is getting up for the first time after a period of bed rest. The nurse should first: A. Assess respiratory function. B. Obtain a baseline blood pressure. C. Assist the patient to sit at the edge of the bed. D. Ask the patient is she feels lightheaded. B. Obtain a baseline blood pressure. To promote respiratory function in the immobilized client, the nurse should: A. Encourage deep breathing and coughing every hour. B. Use oxygen and nebulizer treatments regularly. C. Change the patient's position every 4-8 hrs. D. Suction the patient every hour. A. Encourage deep breathing and coughing every hour. Anti-embolism hoses (stockings) are ordered for the patient on bed rest after surgery. The nurse explains to the patient that the primary purpose of the elastic stockings is to: A. Keep the skin warm and dry. B. Prevent abnormal joint flexion. C. Apply external pressure. D. Prevent bleeding. C. Apply external pressure. To provide for the psychosocial needs of an immobilized patient, an appropriate statement by the nurse is which of the following: A. "The staff will limit your visitors so that you will not be bothered". B. "A roommate can be a real bother. You'd probably rather have a private room." C. "Let's discuss the routine to see if there are any changes we can make." D. "I think you should have your hair done and put on some makeup". C. "Let's discuss the routine to see if there are any changes we can make." To reduce the chance of external hip rotation in a patient on prolonged bed rest, the nurse should implement the use of a: A. Footboard. B. Trapeze bar. C. Bed board. D. Trochanter roll. D. Trochanter roll. To reduce the chance of plantar flexion (foot drop) in a patient on prolonged bed rest, the nurse should implement the use of: A. Trapeze bars. B. High top sneakers. C. Trochanter rolls. D. 30* lateral positioning. B. High top sneakers. Which of the following observations by the nurse indicates the correct use by the patient of a walker without wheels? A. Moving forward with both feet and then advancing the walker. B. Moving 1 foot forward, advancing the walker, and then moving the other foot. C. Sliding the walker while shuffling both feet forward. D. Lifting the walker forward 1 step, placing it on the ground, and then steeping forward into the walker. D. Lifting the walker forward 1 step, placing it on the ground, and then steeping forward into the walker. Which of the following is the best choice of protein for the immobile patient? A. Hot dog. B. Grilled chicken. C. Macaroni and cheese. D. Grilled cheese sandwich. B. Grilled chicken. For the patient who is standing erect, which of the following indicates correct use of crutches? A. Axillary padding removed. B. Crutches placed 10-12 inches to either side of each foot. C. Elbow flexion of 60* for the hand bar. D. Three finger width between the axilla and axillary piece of the crutch. D. Three finger width between the axilla and axillary piece of the crutch. Which of the following is not accurate regarding a trapeze bar for an immobilized patient? A. It can be used for repositioning. B. Bilateral upper extremity strength is required. C. It can be used for independent, nonweightbearing transfer to a chair. D. It's use allows for increased musculoskeletal strength. C. It can be used for independent, nonweightbearing transfer to a chair. With advanced age, which of the following normal physiological changes in sensory function occurs? A. Decreased sensitivity to glare. B. Increased number of taste buds. C. Decreased sensitivity to pain. D. Difficulty discriminating Vowel sounds. C. Decreased sensitivity to pain. Which of the following occupations poses the least risk for sensory alterations? A. Librarian. B. Welder. C. Computer programmer. D. Construction worker. A. Librarian. The nurse is working with a patient with a moderate hearing impairment. To promote communication with this patient, the nurse should: A. Use a louder tone of voice than normal. B. Select a public area to have a conversation. C. Approach a patient quietly from behind before speaking. D. Use visual aids such as the hands and eyes when speaking. D. Use visual aids such as the hands and eyes when speaking. Patient has experienced a cerebrovascular accident with resultant expressive aphasia. The nurse promotes communication with this patient by: A. Speaking loudly and slowly. B. Speaking to the patient on the unaffected side. C. Using a picture chart for the patients responses. D. Using hand gestures to convey information to the patient. C. Using a picture chart for the patients responses. The patient was working in the kitchen and was splashed in the face with a caustic cleaning agent. His eyes were affected and he was brought to the hospital for treatment. After cleansing and evaluation, his eyes were bandaged. When assisting this patient to eat, the nurse should: A. Feed the patient the entire meal. B. Allow the patient to experiment with foods. C. Encourage the family to feed the patient. D. Orient the patient to the location of the foods on the plate. D. Orient the patient to the location of the foods on the plate. An older adult patient in a nursing home has visual and hearing loss. The nurse is alert to which of the following signs represents the effects of sensory deprivation? A. Depression. B. Diminished anxiety. C. Improved task completion. D. Decreased need for physical stimulation. A. Depression. During a home safety assessment, the nurse identifies that there are a number of hazards present. Of the following hazards that are noted by the nurse, which one represents the greatest risk for this patient with diabetic peripheral neuropathy? A. Cluttered walkways. B. Absence of smoke detectors. C. Improper heater settings. D. Lack of bathroom grab bars. C. Improper heater settings. The nurse in the pediatric clinic is checking the basic visual activity of a 3.5 year old child. The nurse should have the child: A. Identify crayon colors. B. Read the standards snellen chart. C. Read a few lines from a children's book. D. Follow the peripheral movement of an object. A. Identify crayon colors. For a patient with receptive aphasia, which of the following nursing interventions is the most effective? A. Providing the patient with a letter chart to use to answer complex questions. B. Using a system of simple gestures to communicate. C. Speaking louder and slower. D. Obtaining a referral for a speech therapist. B. Using a system of simple gestures to communicate. The nurse recommends follow up auditory testing for a child who was exposed in utero to: A. Rubella. B. Excessive oxygen. C. Alcohol. D. Respiratory infection. A. Rubella. The nurse is working with older adult patients in an extended care facility. To enhance the patient's gustatory sense, the nurse should: A. Mix foods together. B. Assist with oral hygiene. C. Make sure foods are extremely spicy. D. Provide foods of similar texture and consistency. B. Assist with oral hygiene. A home safety measure specific for a patient with diminished olfaction is the use of: A. Extra lighting in hallways. B. Amplified telephone receivers. C. Smoke detectors on all levels. D. Mild water heater temperatures. C. Smoke detectors on all levels. The nurse has completed the admission assessment for a patient admitted to the hospitals subacute care unit. Of the following nursing diagnosis identified by the nurse, which takes the highest priority? A. Isolation from social activity. B. Potential for injury. C. Inability to manage adjustment. D. Ineffective verbal communication. B. Potential for injury. The patient is being discharged to home after being evaluated for meniere disease and episodes of dizziness. Which one of the following statements alerts the nurse that further reinforcement is necessary for safety? A. "I'll be careful in the morning when I first get out of bed". B. "It will be good to get back to my job on the train". C. "I have a small bench that I can use when I'm taking a shower". D. "I'm going to be changing to brighter lightbulbs in the hallway". B. "It will be good to get back to my job on the train". The nurse recognizes the stages of sleep and knows that a patient is most easily aroused in which stage? A. NREM 1. B. NREM 2. C. NREM 3. D. NREM 4. A. NREM 1. Which of the following is an antidepressant medication that be be prescribed to promote sleep? A. Elavil. B. Haldol. C. Versed. D. Benadryl. A. Elavil. Which of the following is associated with a patient who has hypersomnia? A. Sleeping less than six hours a night. B. Having trouble waking up in the morning. C. Falling asleep during a conversation. D. Having difficulty falling asleep. B. Having trouble waking up in the morning. The patient has expressed difficulty in sleeping. On further investigation by the nurse, the patient identifies the following behaviors. Which one should the nurse focus on that may be interfering with the patient's sleep? A. Exercising after work. B. Taking a warm bath before bedtime. C. Having 1 or 2 glasses of wine after dinner. D. Eating a bedtime snack fo crackers and juice. C. Having 1 or 2 glasses of wine after dinner. The mother of a 2 year old tells the nurse that the child has started crying and resisting going to sleep at scheduled bedtime. The nurse should advise the patient to: A. Offer the child to a bedtime snack. B. Eliminate of the naps during the day. C. Allow the child to sleep longer in the mornings. D. Maintain consistency in the same bedtime ritual. D. Maintain consistency in the same bedtime ritual. An 11-year-old child in middle school is currently experiencing sleep related to fatigue during classes. Which of the following should the nurse as the patient first? A. "What are the child's usual sleep patterns?" B. "Is there anything else going on at home or school?" C. "Do you think that there is a medical reason for this problem?" D. "Are you allowing the child to stay up?" A. "What are the child's usual sleep patterns?"` In describing the sleep patterns of older adults, the nurse recognizes that they: A. Require more than sleep than middle aged adults. B. Are more difficult to arouse. C. Take less time to fall asleep. D. Have a decline in NREM 3 sleep. D. Have a decline in NREM 3 sleep. For a patient who is currently taking a diuretic, the nurse should inform the patient that he or she may experience: A. Nocturia. B. Nightmares. C. Reduce REM sleep. D. Increased daytime sleepiness. A. Nocturia. As a result of recent studies regarding sudden infant death syndrome and infant safety during sleep, the nurse instructs the parent to: A. Cover the infant loosely with a blanket. B. Provide a stuffed toy for comfort. C. Place the infant on her back. D. Use small pillows in the crib. C. Place the infant on her back. A 74-year-old patient has been having sleeping difficulties. To have better idea of the patient's problem, the nurse should respond with which of the following? A. "What do you do just before going to bed?" B. "Why don't you try napping during the daytime?" C. "You should always eat something just before bedtime." D. "Let's make sure that your bedroom is completely darkened at night." A. "What do you do just before going to bed?" Which of the following information provided by the patient's bed partner is most associated with sleep? A. Restlessness. B. Talking during sleep. C. Somnambulism. D. Excessive snoring. D. Excessive snoring. In teaching methods to promote positive sleep habits at home, the nurse instructs the patient to: A. Use the bedroom only for sleep or sexual adults. B. Eat a meal 1 to 2 hours before bedtime. C. Exercise vigorously before bedtime. D. Stay in bed if sleep does not come after half an hour. A. Use the bedroom only for sleep or sexual adults. The nurse is discussing sleep habits with a patient in the sleep assessment clinic. Of the following activities performed before sleeping, the nurse is alert to the one that may be interfering with the patient sleep, which is: A. Listening to classical music. B. Finishing office work. C. Drinking warm milk. D. Reading novels. B. Finishing office work. Hold our adults at the community center are having a discussion on health issues that is being led by a nurse volunteer. One of the participants asks the nurse what to do about not being able to sleep well at night. The nurse informs the participants that sleep in the evening maybe enhance to by: A. Drinking an alcoholic beverage before bedtime. B. Using an over the counter sleeping agent. C. Wearing loose/ comfortable clothing. D. Eating a large meal before bedtime. C. Wearing loose/ comfortable clothing. 1. You are caring for a client who has diabetes complicated by kidney disease. You need to make a detailed assessment when administering medications because this client may experience problems with: A. absorption. B. biotransformation. C. distribution. D. excretion. D 3. If a nurse experiences a problem reading a physician's medication order, the most appropriate action will be to: A. call the physician to verify order B. call the pharmacist to verify order. C. consult with other nursing staff to verify. D. withhold the medication until physician makes rounds. A 4. Nurses are legally required to document medications that are administered to patients. The nurse is mandated to document which of the following? A. Medication before administering it. B. Medication after administering it. C. Rationale for administering it. D. Prescriber rationale for prescribing it. B Time it takes after a medication is administered for it to produce a response onset Time it takes for a medication to reach its highest effective concentration peak Minimum blood serum concentration of medication reached just before the next scheduled dose trough Time during which medication is present in concentration great enough to produce a response duration 1 ml 15 drops 5 ml 1 teaspoon 15 ml 1 tablespoon 30 ml 2 tablespoons 1. It is important to take precautions to prevent medication errors. A nurse is administering an oral tablet to a patient. Which of the following steps is the second check for accuracy in determining the patient is receiving the right medication? 1. Logging on to automated dispensing system (ADS) or unlocking medicine drawer or cart. 2. Before going to patient's room, comparing patient's name and name of medication on label of prepared drugs with MAR. 3. Selecting correct medication from ADS, unit-dose drawer, or stock supply and comparing name of medication on label with MAR or computer printout. 4. Comparing MAR or computer printout with names of medications on medication labels and patient name at patient's bedside. 2 3. An older adult states that she cannot see her medication bottles clearly to determine when to take her prescription. What should the nurse do? (Select all that apply.) 1. Provide a dispensing system for each day of the week. 2. Provide larger, easier-to-read labels. 3. Tell the patient what is in each container. 4. Have a family caregiver administer the medication. 5. Use teach-back to ensure that the patient knows what medication to take and when. 1, 2, 5 4. The nurse must take a verbal order during an emergency on the unit. Which of the following guidelines can be used for taking verbal or telephone orders? (Select all that apply). 1. Only authorized staff may receive and record verbal or telephone orders. The health care agency identifies in writing the staff who are authorized. 2. Clearly identify patient's name, room number, and diagnosis. 3. Read back all orders to health care provider. 4. Use clarification questions to avoid misunderstandings. 5. Write "VO" (verbal order) or "TO" (telephone order), including date and time, name of patient, and complete order; sign the name of the health care provider and nurse. 1, 2, 3, 4, 5 5. A nurse is administering ophthalmic ointment to a patient. Place the following steps in correct order for the administration of the ointment. 1. Clean eye, washing from inner to outer canthus. 673 2. Assess patient's level of consciousness and ability to follow instructions. 3. Apply thin ribbon of ointment evenly along inner edge of lower eyelid on conjunctiva. 4. Have patient close eye and rub lightly in a circular motion with a cotton ball. 5. Ask patient to look at ceiling, and explain the steps to patient. 2, 1, 5, 3, 4 6. The nurse is administering an IV push medication to a patient who has a compatible IV fluid running through intravenous tubing. Place the following steps in the appropriate order. 1. Release tubing and inject medication within amount of time recommended by agency policy, pharmacist, or medication reference manual. Use watch to time administration. 2. Select injection port of IV tubing closest to patient. Whenever possible, injection port should accept a needleless syringe. Use IV filter if required by medication reference or agency policy. 3. After injecting medication, release tubing, withdraw syringe, and recheck fluid infusion rate. 4. Connect syringe to port of IV line. Insert needleless tip or small-gauge needle of syringe containing prepared drug through center of injection port 5. Clean injection port with antiseptic swab. Allow to dry. 6. Occlude IV line by pinching tubing just above injection port. Pull 2, 5, 4, 6, 1, 3 7. A nurse is administering a metered-dose inhaler (MDI) with a spacer to a patient with chronic obstructive pulmonary disease. Place the steps of the procedure in the correct order. 1. Insert MDI into end of spacer. 2. Perform a respiratory assessment. 3. Remove mouthpiece from MDI and spacer device. 4. Place the spacer mouthpiece into patient's mouth, and instruct patient to close lips around the mouthpiece. 5. Depress medication canister, spraying 1 puff into spacer device. 6. Shake inhaler for 2-5 seconds. 7. Instruct patient to hold breath for 10 seconds. 8. Instruct patient to breathe in slowly through mouth for 3 to 5 seconds. 2, 3, 6, 1, 4, 5, 8, 7 8. A patient is to receive medications through a small-bore nasogastric feeding. Which nursing actions are appropriate? (Select all that apply.) 1. Verifying tube placement after medications are given 2. Mixing all medications together to give all at once 3. Using an enteral tube syringe to administer medications 4. Flushing tube with 30 to 60 mL of water after the last dose of medication 5. Checking for gastric residual before giving the medications 6. Keeping the head of the bed elevated 30 to 60 minutes after the medications are given 3, 4, 5, 6 9. Place the steps of administering an intradermal injection in the correct order. 1. Inject medication slowly. 2. Note the presence of a bleb. 3. Advance needle through epidermis to 3 mm. 4. Using nondominant hand, stretch skin over site with forefinger. 5. Insert needle at a 5- to 15-degree angle into the skin until resistance is felt. 6. Cleanse site with antiseptic swab. 6, 4, 5, 3, 1, 2 10. After receiving an intramuscular (IM) injection in the deltoid, a patient states, "My arm really hurts. It's burning and tingling where I got my injection." What should the nurse do next? (Select all that apply.) 1. Assess the injection site. 2. Administer an oral medication for pain. 3. Notify the patient's health care provider of assessment findings. 4. Document assessment findings and related interventions in the patient's medical record. 5. This is a normal finding, so nothing needs to be done. 6. Apply ice to the site for relief of burning pain. 1, 3, 4 The nurse is obtaining a sexual history from an adolescent male. Which of the following would be the best way to begin the sexual history interview? 1.Often young men your age... 2.I worry that you might... 3.Do you... 4.You don't...do you? 1 The nurse is reviewing the importance of testicular self-examination (TSE) with a 17-year-old male. Which statement by the client confirms the client's understanding of TSE? 1."I will check my testicles for lumps in the shower." 2."I will bear down and check my groin area while seated." 3."I will check my testicles while lying on my right side." 4."I will have my testicles examined by my health care provider every year." 1 The parent of a newborn girl is concerned because the baby's vagina and clitoris appear large and swollen. What is the nurse's best response? 1."This is a normal finding in newborn girls and should resolve within a few weeks." 2."I would make an appointment to see your infant's pediatrician as soon as you get her home." 3."The infant will need some additional tests to determine the cause of this problem." 4."We will have the doctor examine the infant right away." 1 When a female client with an indwelling urinary (Foley) catheter insists on walking to the hospital lobby to visit with family members, nurse Rose teaches how to do this without compromising the catheter. Which client action indicates an accurate understanding of this information? A. The client sets the drainage bag on the floor while sitting down. B. The client keeps the drainage bag below the bladder at all times C. The client clamps the catheter drainage tubing while visiting with the family D. The client loops the drainage tubing below its point of entry into the drainage bag B The nurse is reviewing a client's fluid intake and output record. Fluid intake and urine output should relate in which way? A. Fluid intake should be double the urine output B. Fluid intake should be approximately equal to the urine output C. Fluid intake should be half the urine output D. Fluid intake should be inversely proportional to the urine output B The nurse is reviewing the report of a client's routine urinalysis. Which value should the nurse consider abnormal? A.Specific gravity of 1.005 B.Urine pH of 3.0 C.Absence of protein D.Absence of glucose B Nurse Mary is inserting a urinary catheter into a client who is extremely anxious about the procedure. The nurse can facilitate the insertion by asking the client to: A. breathe deeply B.initiate a stream of urine C.turn to the side D.hold the labia or shaft of penis A While performing a cardiac assessment on a client with an incompetent heart value, the nurse auscultates an incompetent heart valve, the nurse auscultates a murmur. The nurse documents the findings. As describes. The sound as which? A. Lub-dub sound B. Scratchy, leathery heart noise C. A blowing or swooshing noise D. Abrupt, high-pitched snapping noise C A client is wearing a continuous cardiac monitor, which begins to sound its alarm. The nurse sees no electrocardiographic complexes on the screen. Which is the priority nursing action? A. Call a code B. Check the client's status C. Call the healthcare provider D. Document the lack of complexes B A nurse is caring for a client with heart failure. On assessment, the nurse notes that the client is dyspneic, and crackles are audible on auscultation. What additional manifestations would the nurse expect to note in this client if excess fluid volume is present? A. Weight loss and dry skin B. Flat neck veins and decreased urinary output C. An increase in blood pressure and increased respirations D. Weakness and decreased central venous pressure C The nurse is caring for a client with several broken ribs. The client is most likely to experience what type of acid imbalance? A. Respiratory acidosis from inadequate ventilation B. Respiratory alkalosis from anxiety and hyperventilation C. Metabolic acidosis from calcium loss due to broken bones D. Metabolic alkalosis from taking analgesics containing base products A before meals ac twice each day bid after meals pc whenever there is a need prn every morning q am every hour qh every day daily every 4 hours q4h 4 times per day qid give immediately STAT 3 times per day tid buccal medication effects local on mucosa, systemic on saliva topical medication effect local topical medication has systemic effects if the client's skin is the client's skin is broken