Fundamentals 1
Remove the restraints one at a time - -A nurse is caring for al older client who is
violent and attempting to disconnect her IV lines. The provider prescribes soft wrist
restraints. Which of the following actions should the nurse take while the client is in
restraints?
Temporal - -A nurse is planning to obtain vitals of a 2-year-old child who is
experiencing diarrhea & who may have a right ear infection. Which of the following routes
should the nurse use to obtain the temperature?
Sit & Hold the client's hand - -A nurse is caring for a client who is in the terminal
stage of cancer. Which of the following actions should the nurse take when she observes
the client crying?
Notify the provider about the client's decision - -A nurse is preparing for a client who
is scheduled for a hysterectomy for transport to the O.R. when the client states she no
longer wants have the surgery. Which of the following actions should the nurse take?
"Donate autologous blood before the surgery" - -A nurse is reinforcing teaching with
a client who is scheduled for arthroplasty in the next month and might require a blood
transfusion. The client expresses concern about the risk of acquiring an infection from the
blood transfusion. What should the nurse suggest?
Count apical pulse for 1 minute & describe the rhythm in the chart - -A nurse is
measuring vitals for a client and notices an irregularity in the pulse. Which of the following
actions should the nurse take?
"There are times I should use soap & water rather than an alcohol-based hand rub to clean
my hands" - -A nurse is instructing an A.P. about proper hand hygiene. Which of the
following statements by the A.P. indicates an understanding of the teaching?
, Fundamentals 1
"I keep having nightmares about my upcoming surgery." - -A nurse is in an oncology
clinic is collecting data for a client who is undergoing treatment for ovarian cancer. Which
of the following statements by the client indicates she is experiencing psychological
distress?
"I should expect my heart rate to take longer to return to normal after exercise as I get
older." - -A nurse is reinforcing teaching with a group of older adults about expected
changes of aging. Which of the following statements by a group member indicates that the
teaching has been effective?
Place the bladder of the cuff over the posterior aspect of the thigh - -A nurse is
obtaining blood pressure in a client's lower extremity. Which of the following actions should
the nurse take?
Absent bowel sounds w/distention - -A nurse is collecting data for the health history
of a client who is postoperative & has paralytic ileus. Which of the following findings should
the nurse expect?
Carefully remove the gloves & perform proper hand hygiene - -A nurse is drawing
blood for a lab test from a client that results in a blood spill on her gloved hand. The client
has no documented bloodstream infection. Which of the following actions should the
nurse take?
Screening groups of older adults in nursing care facilities for early influenza manifestations
- -A nurse is assisting w/planning a community campaign about seasonal influenza.
Which of the following plans should be included as a secondary prevention strategy?
"Using a cuff that is too small will result in an accurately high reading" - -A nurse
observes an A.P. to obtain blood pressure w/regular-sized cuff for a client who is obese.
Which of the following explanations should the nurse give the A.P?
Remove the restraints one at a time - -A nurse is caring for al older client who is
violent and attempting to disconnect her IV lines. The provider prescribes soft wrist
restraints. Which of the following actions should the nurse take while the client is in
restraints?
Temporal - -A nurse is planning to obtain vitals of a 2-year-old child who is
experiencing diarrhea & who may have a right ear infection. Which of the following routes
should the nurse use to obtain the temperature?
Sit & Hold the client's hand - -A nurse is caring for a client who is in the terminal
stage of cancer. Which of the following actions should the nurse take when she observes
the client crying?
Notify the provider about the client's decision - -A nurse is preparing for a client who
is scheduled for a hysterectomy for transport to the O.R. when the client states she no
longer wants have the surgery. Which of the following actions should the nurse take?
"Donate autologous blood before the surgery" - -A nurse is reinforcing teaching with
a client who is scheduled for arthroplasty in the next month and might require a blood
transfusion. The client expresses concern about the risk of acquiring an infection from the
blood transfusion. What should the nurse suggest?
Count apical pulse for 1 minute & describe the rhythm in the chart - -A nurse is
measuring vitals for a client and notices an irregularity in the pulse. Which of the following
actions should the nurse take?
"There are times I should use soap & water rather than an alcohol-based hand rub to clean
my hands" - -A nurse is instructing an A.P. about proper hand hygiene. Which of the
following statements by the A.P. indicates an understanding of the teaching?
, Fundamentals 1
"I keep having nightmares about my upcoming surgery." - -A nurse is in an oncology
clinic is collecting data for a client who is undergoing treatment for ovarian cancer. Which
of the following statements by the client indicates she is experiencing psychological
distress?
"I should expect my heart rate to take longer to return to normal after exercise as I get
older." - -A nurse is reinforcing teaching with a group of older adults about expected
changes of aging. Which of the following statements by a group member indicates that the
teaching has been effective?
Place the bladder of the cuff over the posterior aspect of the thigh - -A nurse is
obtaining blood pressure in a client's lower extremity. Which of the following actions should
the nurse take?
Absent bowel sounds w/distention - -A nurse is collecting data for the health history
of a client who is postoperative & has paralytic ileus. Which of the following findings should
the nurse expect?
Carefully remove the gloves & perform proper hand hygiene - -A nurse is drawing
blood for a lab test from a client that results in a blood spill on her gloved hand. The client
has no documented bloodstream infection. Which of the following actions should the
nurse take?
Screening groups of older adults in nursing care facilities for early influenza manifestations
- -A nurse is assisting w/planning a community campaign about seasonal influenza.
Which of the following plans should be included as a secondary prevention strategy?
"Using a cuff that is too small will result in an accurately high reading" - -A nurse
observes an A.P. to obtain blood pressure w/regular-sized cuff for a client who is obese.
Which of the following explanations should the nurse give the A.P?
