FUNDS FINAL Part 6 Fundamentals Skills Exam |Questions and Verified Answers - Chamberlain

A nurse is using SBAR communication technique during a crisis. Which nursing intervention reflects "R" step of this technique? A. recording the reaction of the patient to the crisis B. reassessing the pt after medical intervention C. recommending a potential action to manage the crisis D. reporting the situation to the primary health-care provider C Which activity is the nurse engaged in when identifying a nursing diagnosis? A. discovering causes of disease B. documenting desired expected outcomes C. planning care to meet nursing needs of a pt D. planning care to meet nursing needs of a pt D The nurse is caring for a pt with a healing stage III pressure ulcer. Upon entering the room the nurse notices an odor and observes a purulent discharge. Along with increased redness at the wound site. What is the next best step for the nurse? A. notify the charge nurse about the change in status and the potential for infection B. notify the PCP by utilizing SBAR C. complete the head to toe assessment and include current treatment, vitals, and lab results D. notify the wound care nurse about the change in status and the potential for infection C Which nursing action is an example of the assessment step of the nursing process? A. administering pain meds for a headache B. taking a pt's BP after ambulating C. communicating info obtained from an interview D. determining if a pt tolerated the change from a soft to a regular diet C The nurse is preparing to administer meds to 2 pts w/ the same last name. After the administration the nurse realizes she did not check the identification of the pt before administering meds. Which of the following actions should the nurse complete first? A. return to the room and assess the pt B. administer the antidote to the pt immediately C. alert the charge nurse that a med error has occurred D. complete proper documentation of the medication error in the pts chart A The nurse is assessing a pt. What info collected by the nurse reflects subjective information? A. clammy skin B. agitated behavior C. numbness of the feet D coughing after a deep breath C The nurse is assessing a pt. What clinical manifestation experienced by the pt. is an example of objective information? A. edema B. heartburn C. chest pain D. lightheadedness A A nurse is assessing a pt who has a wound on the leg as a result of a bike accident. Which clinical manifestation indicated a localized inflammatory response? A. body temp of 101.4F B. heart rate is 103 bpm C. area around the wound is swollen D. Exudate from the wound is greenish yellow C Which action is unique to maintaining airborne precautions for a pt w/ a diagnosis of suspected primary TB A. maintaining negative air pressure in the room B. wearing a surgical mask when in the room C. donning a gown when entering the room D. wearing gloves when entering the room A A nurse is assessing a pt who had numerous stitched several days ago for a traumatic injury to the base of the right index finger. Which assessment of the site indicates that the inflammatory response has progressed to an infectious process? A. yellow discharge B. swelling around the site C. inability to flex the finger D. feeling of heat when touched A Which action is essential when maintaining standard precautions? A. putting on a gown when changing soiled linen B. wearing goggles when changing a dry sterile dressing C. wearing gloves during contact w/ a pts body fluids D. donning a mask w/ an eye shield when entering a pts room C & A A primary health care provider orders warm compresses to be applied to the site of an intravenous catheter that had become red and inflamed. What should the nurse explain to the pt is the desired outcome of this therapy? A. the area will feel less tense, which will decrease the risk of bleeding B. circulation to the area will increase which will promote healing C. circulation to the area will decrease which will limit edema D. the area will feel numb, which will decrease discomfort B Which intervention is MOST effective in reducing the major cause of injury in the hospital setting for pts who are older adults? A. assist all older adults with toileting activities B. elevate all bedrails of older adults at night C place a fall precaution sign on the door to a room with an older adult D. identify medications taken by an older adult that may increase the risk of falls D Which nursing intervention is most essential to provide for pt safety, regardless of the pts individual health issue? A. keep the pts bed in the lowest position B. ensure the call bell is within reach C. raise the 4 side rails when in bed D. check the pt every 2 hours A A nurse is caring for a 60 y.o. who is a resident in a rehab center recoering from a right sided brain attack. The pt has orders for out of bed, ambulating w/ assistance as tolerated. Which intervention is most important? A. assessing balance B. using a bed alarm C. encouraging the use of a walker D. teaching to rise slowly from a lying to sitting position A Which nursing action is most important when ambulating a pt w/ a gait belt? A. position yourself slightly in front of and next to the pt when ambulating a pt w/ a gait belt B. adjust the gait belt so tha tno fingers can be inserted between the belt and the pts waist C. assess for activity intolerance while ambulating a pt w/ a gait belt D. hold the gait belt in the middle of the pts. back C