Fundamentals Unit 1 Galen College of Nursing BSN:
Combined fundamentals unit 1 cards with positioning
questions with complete solutions
10. The nurse, at change-of-shift report, learns that one of the
clients in his care has bilateral soft wrist restraints. The client is
confused, is trying to get out of bed, and had pulled out the IV
line, which was subsequently reinserted. Which action(s) by the
nurse is appropriate? Select all that apply. 1. Document the
behavior(s) that require continued use of the restraints. 2. Ensure
that the restraints are tied to the side rails. 3. Provide range-of-
motion exercises when the restraints are removed. 4. Orient the
client. 5. Assess the tightness of the restraints. Correct Answer
1,3,4,5
4. A mother and her 3-year-old live in a home built in 1932.
Which of NANDA nursing diagnosis is most applicable for this
child? cerrorism. 1. Risk for Suffocation bioter- 2. Risk for
Injury 3. Risk for Poisoning be cat- 4. Risk for Disuse Syndrome
es such Correct Answer 3. Risk for Poisoning
A client complains for SOB. During assessment the nurse
observes that the client has edema of the left leg only. The nurse
reviews evidence based practice literature and reflects on a
previous client with the same clinical manifestations. What do
these actions represent?
1. Clinical judgment
2. Clinical reasoning
3. Reflection
4. Intuition Correct Answer 2. Clinical reasoning (see book
answer for chapter 10 pg. 1374 for rationale.)
,A client is being admitted to the hospital because of a seizure
that occurred at his home. The client has no previous history of
seizures. In planning the client's nursing care, which of the
following measures is most essential at this time of admission?
Select all that apply.
1. Place a padded tongue depressor at the head of the bed.
2. Pad the bed with blankets.
3. Inform the client about the importance of wearing a medical
to identification tag.
4. Teach the client about epilepsy.
5. Test oral suction equipment. Correct Answer 2 and 5
A client with diarrhea also has a primary care providers order
for a bulk laxative daily. The nurse, not realizing that bulk
laxative can help solids certain types of diarrhea, concludes,
"The PCP does not know the client has diarrhea." What type of
statement is this? Correct Answer Inference
Abrasion Correct Answer Superficial layers of the skin are
scraped or rubbed away. Area is reddened and may have
localized bleeding or serous weeping.
Acne Correct Answer inflammatory disease of the skin
involving the sebaceous glands and hair follicles.
Keep clean to prevent secondary infection
Actual Diagnosis Correct Answer Presence of associated sign
and symptoms at the time of the assessment
,Example: Ineffective Breathing Pattern
After cataract surgery, how should the patient lay? Correct
Answer The patient should sleep on the unaffected side with a
night shield in place for 1-4 weeks.
After ear surgery (myringotomy) how should the patient be
laying? Correct Answer Position the patient side-lying on
effected side to allow for drainage.
Agents used Commonly on skin Correct Answer -Soap
-CHG (antimicrobial)
-Bath oil (softens skin and prevents chapping, oils can be
slippery so watch out)
-Skin cream, lotion (prevents evaporation and chapping)
-Powder (absorbs water and prevents frictions, commonly used
under breast, some powders can be antibacterial)
-Deodorant (masks smells)
-Antiperspirant (reduces amount of perspiration)
Alternatives for Restraints Correct Answer
Ammonia Dermatitis (Diaper Rash) Correct Answer Caused by
skin bacteria reacting with urea in the urine. The skin becomes
reddened and is sore.
Keep skin dry. Use protection ointments like zinc oxide to areas
at risk.
Boil infants diapers or wash them with antibacterial detergent to
prevent infection. Detergent can be irritation so rinse well.
, Applying Restraints: Correct Answer Obtain informed consent
Get an order from PCP
Apply the restraint to where the client can still move as freely as
possible while remaining safe.
Do not impede circulation
Pad bony prominences
Always tie with a knot that will not tighten when pulled
Never tie the restraint to the side rails!
Assess skin and need for restraints regularly per hospital
protocol
Immediately report reddened or skin breakdown under restraints
Be able to release restraints quickly in times of emergency
Are PRN orders allowed for restraints? Correct Answer NO
Assessing (ADPIE) Correct Answer Collecting, organizing,
validating, and documenting client data.
Data collection:
Observation (Clinical signs, threats to safety, oxygen or iv
tubing in place, Who is at the Beside with the patient)
Interviewing (Closed ended questions (yes or no), open-ended
questions
Examining (objective data (head to toe approach))
Purpose: to establish a database about the client's response to
health concerns or illness and the ability to manage healthcare
needs
Activities:
-Obtain a nursing health history
Combined fundamentals unit 1 cards with positioning
questions with complete solutions
10. The nurse, at change-of-shift report, learns that one of the
clients in his care has bilateral soft wrist restraints. The client is
confused, is trying to get out of bed, and had pulled out the IV
line, which was subsequently reinserted. Which action(s) by the
nurse is appropriate? Select all that apply. 1. Document the
behavior(s) that require continued use of the restraints. 2. Ensure
that the restraints are tied to the side rails. 3. Provide range-of-
motion exercises when the restraints are removed. 4. Orient the
client. 5. Assess the tightness of the restraints. Correct Answer
1,3,4,5
4. A mother and her 3-year-old live in a home built in 1932.
Which of NANDA nursing diagnosis is most applicable for this
child? cerrorism. 1. Risk for Suffocation bioter- 2. Risk for
Injury 3. Risk for Poisoning be cat- 4. Risk for Disuse Syndrome
es such Correct Answer 3. Risk for Poisoning
A client complains for SOB. During assessment the nurse
observes that the client has edema of the left leg only. The nurse
reviews evidence based practice literature and reflects on a
previous client with the same clinical manifestations. What do
these actions represent?
1. Clinical judgment
2. Clinical reasoning
3. Reflection
4. Intuition Correct Answer 2. Clinical reasoning (see book
answer for chapter 10 pg. 1374 for rationale.)
,A client is being admitted to the hospital because of a seizure
that occurred at his home. The client has no previous history of
seizures. In planning the client's nursing care, which of the
following measures is most essential at this time of admission?
Select all that apply.
1. Place a padded tongue depressor at the head of the bed.
2. Pad the bed with blankets.
3. Inform the client about the importance of wearing a medical
to identification tag.
4. Teach the client about epilepsy.
5. Test oral suction equipment. Correct Answer 2 and 5
A client with diarrhea also has a primary care providers order
for a bulk laxative daily. The nurse, not realizing that bulk
laxative can help solids certain types of diarrhea, concludes,
"The PCP does not know the client has diarrhea." What type of
statement is this? Correct Answer Inference
Abrasion Correct Answer Superficial layers of the skin are
scraped or rubbed away. Area is reddened and may have
localized bleeding or serous weeping.
Acne Correct Answer inflammatory disease of the skin
involving the sebaceous glands and hair follicles.
Keep clean to prevent secondary infection
Actual Diagnosis Correct Answer Presence of associated sign
and symptoms at the time of the assessment
,Example: Ineffective Breathing Pattern
After cataract surgery, how should the patient lay? Correct
Answer The patient should sleep on the unaffected side with a
night shield in place for 1-4 weeks.
After ear surgery (myringotomy) how should the patient be
laying? Correct Answer Position the patient side-lying on
effected side to allow for drainage.
Agents used Commonly on skin Correct Answer -Soap
-CHG (antimicrobial)
-Bath oil (softens skin and prevents chapping, oils can be
slippery so watch out)
-Skin cream, lotion (prevents evaporation and chapping)
-Powder (absorbs water and prevents frictions, commonly used
under breast, some powders can be antibacterial)
-Deodorant (masks smells)
-Antiperspirant (reduces amount of perspiration)
Alternatives for Restraints Correct Answer
Ammonia Dermatitis (Diaper Rash) Correct Answer Caused by
skin bacteria reacting with urea in the urine. The skin becomes
reddened and is sore.
Keep skin dry. Use protection ointments like zinc oxide to areas
at risk.
Boil infants diapers or wash them with antibacterial detergent to
prevent infection. Detergent can be irritation so rinse well.
, Applying Restraints: Correct Answer Obtain informed consent
Get an order from PCP
Apply the restraint to where the client can still move as freely as
possible while remaining safe.
Do not impede circulation
Pad bony prominences
Always tie with a knot that will not tighten when pulled
Never tie the restraint to the side rails!
Assess skin and need for restraints regularly per hospital
protocol
Immediately report reddened or skin breakdown under restraints
Be able to release restraints quickly in times of emergency
Are PRN orders allowed for restraints? Correct Answer NO
Assessing (ADPIE) Correct Answer Collecting, organizing,
validating, and documenting client data.
Data collection:
Observation (Clinical signs, threats to safety, oxygen or iv
tubing in place, Who is at the Beside with the patient)
Interviewing (Closed ended questions (yes or no), open-ended
questions
Examining (objective data (head to toe approach))
Purpose: to establish a database about the client's response to
health concerns or illness and the ability to manage healthcare
needs
Activities:
-Obtain a nursing health history
