Fundamentals Final Test Bank.docx

A nurse caring for a client who has an infected wound removes a dressing saturated with blood and purulent drainage. How should the nurse dispose of the dressing material? A. Discard the dressing in the bedside trash receptacle. B. Dispose of the dressing in a biohazardous waste container. C. Enclose the dressing in a single clear plastic bag and discard in the bedside trash receptacle. - correct answer B. Dispose of the dressing in a biohazardous waste container. A nurse is caring for a female client who has recurrent kidney stones and is scheduled for an intravenous pyelogram. Which of the following statements should the nurse report to the provider? A. "I drink at least 2 quarts of fluid every day." B. "The last time I voided it was painful and red-tinged." C. "My period ended 2 days ago." D. "I don't eat shellfish because it gives me hives." - correct answer D. "I don't eat shellfish because it gives me hives." A nurse is preparing to administer 40 mEq of potassium chloride in 45% sodium chloride (NaCl) 500 mL IV to infuse 10 mEq/hr. The nurse should set the IV pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.) CALCULATION - correct answer 125 mL/hr A nurse working for a home agency is assessing an older adult male client. Which of the following findings is the priority for the nurse to address? A. Swollen gums B. Pruritus C. Urinary Hesitancy D. Dysphagia - correct answer D. Dysphagia A nurse is going to give a presentation about preventing deep-vein thrombosis (DVT). Which of the following should the nurse include as a risk factor for this disorder? (Select all that apply.) BMI of 20 Recent long flight Hypertension High calcium intake Immobility - correct answer Flights Immobility A nurse is teaching a client who has a prescription of a nasogastric tube (NG) to treat a pyloric obstruction. Which of the following rationales for the use of the nasogastric tube should the nurse include in the teaching? A. Determine the pH of the gastric secretions. B. Supply nutrients via tube feedings. C. Decompress the stomach. D. Administer medications. - correct answer C. Decompress the stomach. A nurse provides a back massage as a palliative care measure to a client who is unconscious, grimacing, and restless. Which of the following findings should the nurse identify as indicating a therapeutic response? (Select all that apply.) The shoulders droop. The facial muscles relax. The respiratory rate increases. The pulse is within the expected range. The client draws his legs up into a fetal position. - correct answer The shoulders droop. The facial muscles relax. The pulse is within the expected range. A nurse is assessing a client who is postoperative and has anemia due to excess blood loss following surgery. Which of the following findings should the nurse expect? A. Fatigue B. Hypertension C. Bradycardia D. Diarrhea - correct answer A. Fatigue A nurse is reviewing the arterial blood gas (ABG) results of a client who the provider suspects has metabolic acidosis. Which of the following results should the nurse expect to see? A. pH below 7.35 B. HCO3 above 26 mEq/L C. PaO2 below 70 mmHg D. PaCO2 above 45 mmHg - correct answer A. pH below 7.35 A hospice nurse is reviewing the prescriptions for a client who is receiving palliative care. Which of the following prescriptions should the nurse expect? (Select all that apply.) Provide skin care with a moisture barrier cream. Administer artificial tear PRN. Obtain vital signs every 2 hr. Perform mouth care every hour. Administer oxygen 2L/min via nasal cannula. - correct answer Provide skin care with a moisture barrier cream. Administer artificial tear PRN. Perform mouth care every hour. Administer oxygen 2L/min via nasal cannula. A nurse is planning care for a client who is postoperative and at risk of paralytic ileus. Which of the following interventions should the nurse plan to take to promote peristalsis? A. Increase ambulation. B. Decrease fluid intake. C. Increase protein intake. D. Offer the client the bedpan every 2 hr. - correct answer A. Increase ambulation. A nurse has completed care procedures for a client who requires airborne precautions. Which of the following items of personal protective equipment (PPE) should the nurse remove last? A. Mask B. Gloves C. Gown D. Goggles - correct answer A. Mask A nurse is providing teaching to an assistive personnel (AP) about caring for clients with restraints. Which of the following statements by the AP indicates an understanding of the teaching? A. "I will tie restraints in double knots." B. "I will tie a restraint to the portion of the bed that moves when the head of the bed is moved." C. "I will ensure that restraints fit tightly against the client." D. "I will put four side rails up if a client is confused." - correct answer B. "I will tie a restraint to the portion of the bed that moves when the head of the bed is moved." A nurse is teaching a new group of assistive personnel (AP) about the importance of hand hygiene. Which of the following statements should the nurse include? A. "If you wear gloves, you do not have to wash your hands." B. "Rub all surfaces of your hands with an alcohol rub for 20 to 30 seconds." C. "Use an alcohol rub when your hands are visibly soiled." D. "If you don't have an infection, your hands won't infect others." - correct answer B. "Rub all surfaces of your hands with an alcohol rub for 20 to 30 seconds." A nurse is planning postoperative care for a client who is scheduled for an ileal conduit (urinary diversion) procedure. The nurse should include which of the following in the client's plan of care? (Select all that apply). Notify the provider immediately if mucus is present in the urine. Maintain the client on a fluid restriction. Apply skin barrier around the stoma site. Educate the client that hematuria is expected following the procedure. Monitor hourly urine output. - correct answer Apply skin barrier around the stoma site. Educate the client that hematuria is expected following the procedure. Monitor hourly urine output.