Fundamentals of Nursing (Saunders 2nd edition)

Make your own Quiz!




CORRECT ANSWERS
1. A client arrives at the surgical unit after nasal surgery. The client has nasal packing in place. The nurse reviews the physician's orders and anticipates that which of the following client positions would be prescribed to reduce swelling?

a. sim's
b. Prone
c. Supine
d. Semi-Fowler's *

2. A client enters the emergency department with a nosebleed. On assessment, the client tells the nurse that the nosebleed just suddenly began. The nurse notes no obvious facial injury. Which of the following would be the initial nursing action?

a. Prepare a nasal baloon for insertion
b. Insert nasal packing
c. Sit the client down, ask the client to lean forward, and apply pressure to the nose for 5 to 10 minutes.*
d. Place the client in a semi-fowlers position and apply ice packs to the nose.

3. A nurse is caring for a client who is receiving total parenteral nutrition (TPN) via a central line. Which nursing intervention would specifically provide assessment data related to the most common complication related to TPN?

a. weighing the client daily
b. Monitoring I&O
c. Monitoring the temperature *
d. Monitoring the serum blood urea nitrogen (BUN)

4. A nurse has developed a teaching plan for an elderly client with hypertension about the administration of prescribed medications. The initial nursing action would be to do which of the following?

a. Assess the client's readiness to learn *
b. Find out if anyone lives with the client
c. Set priorities for the client
d. Use only one teaching method to prevent confusion

5. A female client tells the home health nurse that she has not had a stool since coming home from the hospital after surgery 4 days ago. Which of the following is the most appropriate diet for this client at this time?

a. High-fiber diet*
b. Full-liquid diet
c. Low-residue diet
d. Low-sodium diet

6. A physician has ordered a clear liquid diet for a postoperative client. The nurse prepares to deliver the lunch tray to the client and checks the food tray to be sure that which of the following is true?

a. Sodiums foods are restricted
b. All food item are lukewarm in temperature
c. All food items are liquid at body temperature *
d. At least one serving of low-fat milk is served.

7. A client is being seen in the clinic for sypmtoms of hyperinsulinism. A nurse provides information to the client about dietary measures for the condition. Which of the following diets would be most appropriate to suggest to the client?

a. A low-fiber, high-fat diet
b. Limiting food intake to two meals per day
c. Large amounts of carbohydrates between low-protein meals
d. Small frequent meals with protein, fat, and carbohydrates at each meal *

8. A nurse is developing a plan of care for a client with a nasogastric (NG) tube feeding in place. When formulating the plan of care, the nurse keeps which of the following in mind?

a. Aspiration is a concern with a nasogastric tube feeding. *
b. The client needs to be maintained in supine position.
c. The NG tube needs to be changed with every other feeding.
d. The rate of the feeding needs to be increased if the infusion rate falls behind schedule.

9. A nurse is preparing a plan of care for a client receiving enteral feedings via a gastrotomy tube (G-tube). The nurse plans to include which of the following interventions in the plan of care?

a. To provide oral fluids three times per day
b. To check around the stoma site for skin irritation. *
c. To medicate with antidiarrheal medications everyday.
d. To use sterile technique when administering the tube feedings.

10. A nurse is caring for a client with impaired mobility that occurred as a result of a stroke. The client has right-sided arm and leg weakness. The nurse would suggest that the client use which of the following assistive devices that would provide the best stability for ambulating?

a. Crutches
b. A single straight-legged cane
c. A quad cane *
d. A walker
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11. A nurse is instructing a client who has had a stroke how to ambulate with the use of a cane. Which of the following instructions would the nurse provide to the client?

a. Hold the cane on the affected (weak) side.
b. Hold the cane on the unaffected (strong) side. *
c. Move the cane forward first along with the unaffected (strong) leg.
d. When going down stairs, move the cane and the unaffected (strong) leg down first.

12. The home care nurse visits a client who has been experiencing increased weakness. The client tells the nurse that he is using a cane that was purchased at a local pharmacy. The home care nurse assesses the client's use of the cane and determines that the cane is sized correctly if which of the following is true?

a. The handle of the cane is even with client's waist
b. The client's elbow is flexed at a 15 to 30 degree angle when ambulating with the cane. *
c. The client's elbow is flexed at a 50 to 75 degree angle when ambulating with the cane.
d. The client's elbow is straight when ambulating with the cane.

13. A nurse is caring for a client with a diagnosis of dehydration. The client is receiving intravenous fluids. which of the following assessment data would indicate to the nurse that the dehydration is not resolved?

a. A urine specific gravity of 1.033 *
b. A urine output that is pale yellow in color.
c. A blood pressure of 120/80 mmHg
d. An oral temperature of 98.8 F

14. A registered nurse (RN) is supervising a licensed practical nurse (LPN) administer an intramuscular (IM) injection of iron to an assigned client. The RN would intervene if the nurse observed the LPN perform which of the following?

a. Changing the needle after drawing up the dose and before injection.
b. Preparing an air lock when drawing up the medication
c. Using a Z-tract method for injection.
d. Massaging the injection site well afer injection. *

15. A client is performing an assessment on a client with a diagnosis of pernicious anemia. Which assessment finding would the nurse expect to note in this client?

a. Shortness of breath on exertion.
b. Dyspnea
c. Red tongue that is smooth and sore *
d. Dusky mucous membrane

16. A clinic nurse is reviewing the record of a client with a suspected diagnosis of pernicious anemia. The nurse reviews the physician's orders and anticipates thatr which of the following diagnostic tests will be ordered?

a. Bone marrow biopsy
b. Schilling test *
c. White blood cell differential
d. Clotting time

17. A registered nurse (RN) has instructed a nursing assistant (NA) to administer soap solution enemas until clear to a client scheduled for a colonoscopy. The NA tells the nurse that three enemas have been administered and that the client is still passing brown liquid stool. Which of the following instructions would the RN give to the NA?

a. Wait 30 minutes abd then administer another enema
b. Administer a Fleet enema.
c. Administer an oil-retention enema.
d. Stop administering the enemas until the physician is notified. *

18. A nurse attends an educational conference on leadership styles. The nurse is sitting with a nurse employed at a large trauma center who states that the leadership style at the trauma center is task-oriented and directive. The nurse is describing which of the following leadership styles?

a. Autocratic *
b. Situational
c. Democratic
d. Laissez faire

19. A nurse in the emergency room receives a telephone call from emergency medical services and is told that several victims who survived a plane crash will be transported to the hospital. The nurse is told that several victims are suffering from cold exposure because the plane plummeted and submerged into a local river. Which of the following would be the nurse's initial action?

a. Supply the triage rooms with bottles of sterile water and normal saline.
b. Call the laundry department and ask the department to send as many as warm blankets as possible to the emergency room.
c. Call the nursing supervisor to activate the agency disaster plan. *
d. Call the intensive care unit to request that nurses be sent to the emergency room.

20. The nurse caring for a client with hypocalcemia would expect to note which of the following changes on the electrocardiogram(ECG)?

a. Prominent U wave
b. Widened T wave
c. Shortened ST segment
d. Prolonged QT interval *

21. The nurse caring for a client with severe malnutrition reviews the laboratory results and notes a magnesium level of 1.0 mEq/L. Which ECG change would the nurse expect to note based on the magnesium level?

a. Prominent U wave
b. Depressed ST segment *
c. Widened QRS complex
d. Prologed PR interval