NURSING FUNDAMENTA Foundations QL Answers 2023- Galen College of Nursing

NURSING FUNDAMENTA Foundations QL Answers 2023- Galen College of Nursing After completing an assessment and determining that a client has a problem, which action should the nurse perform next? A.Determine the etiology of the problem. B. Prioritize nursing care interventions. C. Plan appropriate interventions. D. Collaborate with the client to set goals. Ans: A. Rationale Before planning care, the nurse should determine the etiology, or cause, of the problem, because this will help determine goals, plan of care and priorities of interventions. An older resident of a long-term care facility is no longer able to perform self-care and is becoming progressively weaker. The resident previously requested that no resuscitative efforts be performed, and the family requests hospice care. What action should the nurse implement first? A. Reaffirm the client's desire for no resuscitative efforts. B. Transfer the client to a hospice inpatient facility. C. Prepare the family for the client's impending death. D. Notify the healthcare provider of the family's request. Ans: D Rationale When a family requests hospice care, the nurse should first communicate with the healthcare provider. Hospice care is provided for clients with a limited life expectancy, which must be identified by the healthcare provider. Once the healthcare provider supports the transfer to hospice care, the nurse can collaborate with the hospice staff and healthcare provider to determine what additional care should be implemented. When assessing a client with wrist restraints, the nurse observes that the fingers on the right hand are blue. What action should the nurse implement first? A. Loosen the right wrist restraint. B. Apply a pulse oximeter to the right hand. C. Compare hand color bilaterally. D. Palpate the right radial pulse. Ans: A Rationale The nurse has observed that a client's fingers are blue distal to a wrist restraint. The priority nursing action is to restore circulation by loosening the restraint, because blue fingers (cyanosis) indicates decreased circulation. Assessing the depth of color change and the radial pulse are also important nursing interventions, but do not have the priority of removing the restraint. Pulse oximetry measures the saturation of hemoglobin with oxygen and is not indicated in situations where the cyanosis is related to mechanical compression (the restraints). A client with chronic kidney disease (CKD) selects a scrambled egg for his breakfast. Which action should the nurse take? A. Commend the client for selecting a high biologic value protein. B. Remind the client that protein in the diet should be avoided. C. Suggest that the client also select orange juice, to promote absorption. D. Encourage the client to attend classes on dietary management of CKD. Ans: A Rationale Foods such as eggs and milk are high biologic proteins which are allowed because they are complete proteins and supply the essential amino acids that are necessary for growth and cell repair. Although a low-protein diet is followed, some protein is essential. Orange juice is rich in potassium, and should not be encouraged. The client has made a good diet choice, so classes on dietary management is not necessary. A male client with a history of hypertension tells the nurse that he is tired of taking antihypertensive medications and is going to try spiritual meditation instead. What should be the nurse's first response? A. "It is important that you continue your medication while learning to meditate." B. "Spiritual meditation requires a time commitment of 15 to 20 minutes daily." C. "Obtain your healthcare provider's permission before starting meditation." D. "Complementary therapy and western medicine can be effective for you." Ans: A Rationale The prolonged practice of meditation may lead to a reduced need for antihypertensive medications. However, the medications must be continued while the physiologic response to meditation is monitored. The healthcare provider should be informed, but permission is not required to meditate. Although it is true that this complementary therapy might be effective, it is essential that the client continue with antihypertensive medications until the effect of meditation can be measured. The nurse is examining a male client who reports itching on his right arm, The nurse observes a rash made up of multiple flat areas of redness ranging from pinpoint to 0.5 cm in diameter. How should the nurse record this finding? A. Multiple vesicular areas surrounded by redness, ranging in size from 1 mm to 0.5 cm. B. Localized red rash comprised of flat areas, pinpoint to 0.5 cm in diameter. C. Several areas of red, papular lesions from pinpoint to 0.5 cm in size. D. Localized petechial areas, ranging in size from pinpoint to 0.5 cm in diameter. Ans: B Rationale Macules are localized flat skin discolorations less than 1 cm in diameter. However, when recording such a finding the nurse should describe the appearance rather than simply naming the condition. Vesicles are fluid-filled blisters. Papules are solid elevated lesions and petechiae are pinpoint red to purple skin discolorations that do not itch. During the initial morning assessment, a male client denies dysuria but reports that his urine appears dark amber. Which intervention should the nurse implement? A. Provide additional coffee on the client's breakfast tray. B. Exchange the client's grape juice for cranberry juice. C.Bring the client additional fruit at mid-morning. D. Encourage additional oral intake of juices and water. Ans: D Rationale Dark amber urine is characteristic of fluid volume deficit, and the client should be encouraged to increase fluid intake (D). Caffeine, however, is a diuretic (A), and may worsen the fluid volume deficit. Any type of juice will be beneficial (B), since the client is not dysuric, a sign of an urinary tract infection. The client needs to restore fluid volume more than solid foods (C). Which action is most important for the nurse to implement when donning sterile gloves? A. Maintain thumb at a ninety degree angle. B. Hold hands with fingers down while gloving. C. Keep gloved hands above the elbows. D. Put the glove on the dominant hand first. Ans: C Rationale Gloved hands held below waist level are considered unsterile. While it may be helpful to put the glove on the dominant hand first, it is not necessary to ensure asepsis. The nurse is evaluating a client learning about a low-sodium diet. Selection of which meal would indicate to the nurse that this client understands the dietary restrictions? A. Tossed salad, low-sodium dressing, bacon and tomato sandwich. B. New England clam chowder, no-salt crackers, fresh fruit salad. C. Skim milk, turkey salad, roll, vanilla ice cream. D. Macaroni and cheese, diet Coke, a slice of cherry pie. Ans: C Rationale Skim milk, turkey, bread, and ice cream, while containing some sodium, are considered low-sodium foods. Bacon, canned soups (especially those with seafood), hard cheeses, macaroni, and most diet drinks are very high in sodium. The nurse is performing nasotracheal suctioning. After suctioning the client's trachea for fifteen seconds, large amounts of thick yellow secretions return. What action should the nurse implement next? A. Encourage the client to cough to help loosen secretions. B. Advise the client to increase the intake of oral fluids. C. Rotate the suction catheter to obtain any remaining secretions. D. Re-oxygenate the client before attempting to suction again. Ans: D Rationale Nasotracheal suctioning should not be continued for longer than ten to fifteen seconds, since the client's oxygenation is compromised during this time. Additional suctioning may continue after the client has received oxygen. Docusate sodium (Colace) 0.3 grams is prescribed for a client who has frequent constipation. Each capsule contains 100 mg. How many capsules should the nurse administer? Ans: 3 A resident in a skilled nursing facility for short-term rehabilitation after a hip replacement tells the nurse, "I don't want any more blood taken for those useless tests." Which narrative documentation should the nurse enter in the client's medical record? A. Healthcare provider notified of failure to collect specimens for prescribed blood studies. B. Blood specimens not collected because client no longer wants blood tests performed. C. Healthcare provider notified of client's refusal to have blood specimens collected for testing. D. Client irritable, uncooperative, and refuses to have blood collected. Healthcare provider notified. Ans: C Rationale When a client refuses a treatment, the exact words of the client regarding the client's refusal of care should be documented in a narrative format. The nurse should not editorialize, make judgments, or document assumptions about the client's wishes. An older client with a fractured left hip is on strict bedrest. Which nursing measure is essential to the client's nursing care? A. Massage any reddened areas for at least five minutes. B. Encourage active range of motion exercises on extremities. C. Position the client laterally, prone, and dorsally in sequence. D. Gently lift the client when moving into a desired position. Ans: D Rationale To avoid shearing forces when repositioning, the client should be lifted gently across a surface. Reddened areas should not be massaged since this may increase the damage to already traumatized skin. To control pain and muscle spasms, active range of motion may be limited on the affected leg. A client is in the radiology department at 0900 when the prescription levofloxacin (Levaquin) 500 mg IV every 24 hours is scheduled to be administered. The client returns to the unit at 1300. What is the best intervention for the nurse to implement? Contact the healthcare provider and complete a medication variance form. Administer the Levaquin at 1300 and resume the 0900 schedule in the morning. Notify the charge nurse and complete an incident report to explain the missed dose. Give the missed dose at 1300 and change the schedule to administer daily at 1300. Ans: D . . . . . . . .