Capstone Fundamentals Assessment

client with dysphagia, which interventions include in plan

have the client seat upright for 1 hr following meals

Assessing Infussion IV site, client reports pain, site is red, warmth.

What the nurse do

Disontinue Infussion

Routine abdominal assessment. action by the nurse

perform palpitation after ascultation

teachin new nurses about immunity. Include in the teaching

The body produces antibodies in response to an antigen with active immunity

Risk factors for oler adulrs that increase risk of developing infections

Lowered immune system function

Teaching Meter dose Inhaler. What instructions teach

Inhale medication deeply for 3-5 seconds

a nurse is performing a focused assessment on a client who has a history of COPD and is experiencing dyspnea, which of the findings should the nurse expect?

flaring of the nostrils

a nurse is teaching a client about the correct use of a cane, what should the nurse include? (SATA)

ensure the cane has a rubber cap

hold the can on the stronger side

flex the elbow slightly when using the cane

use a quad cane for increased support

1. a nurse is teaching a group of assistive personal about the expected integumentary changes in older adults, which should the nurse include:

a. decreased in elasticity

1. a nurse in a provider's office is assessing a client who reports a decrease in the effectiveness of their arthritis medication. which of the following client information should the nurse identify as a contributing factor to the decrease in the medication's effectiveness?

a. the client has a history of recurring bowel inflammation

1. a nurse is monitoring a client who has been receiving intermittent enteral feedings, what should the nurse identify as an intolerance to the feeding?

a. Nausea

1. a nurse is assisting a client who signed an informed consent form for surgery but has since expressed doubts about the need for surgery, which of the following statements should the nurse make?

The surgeon will answer your questions before surgery

A nurse is preparing to administer meperidine 35mg IM to an adolescent who is preoperative. Available in meperidine 50mg how much should the nurse administer? (Round the to the tenth

0.7 mg

1. a nurse is documenting client care, which of the following entries should the nurse identify as an example of implementation of client care?

a. contacted the provider to report client findings

1. a nurse is assisting with meal planning for a client who has been prescribed a mechanical soft diet. the nurse should instruct the client to avoid which of the following foods?

a. Orange slices

1. a nurse is teaching about measures to promote sleep with insomnia, what statement indicates understanding?

a. I should reduce my fluid intake to 2 hours before bedtime

1. a nurse is assessing the pain level of a client who has dementia and difficulty communicating, which pain assessment technique should the nurse use?

a. Behavioral indicators

1. a nurse is in an emergency department (ED) monitoring the hydration status of a client receiving oral rehydration, what should the intervene for?

a. Heart rate 120/min

1. a nurse in a provider's office is assessing the motor skill development of a 15-month-old toddler during a well-child visit, what gross motor skills should the nurse expect?

walks without assistance using a wide stance

1. a nurse is teaching about safety risks for adolescents, what should be included?

a. at this age, peer influence to participate in high-risk behaviors can lead to injury

1. a nurse is caring for a client who expresses anxiety about an upcoming surgery, what should the nurse do?

a. ask the client to describe feelings

1. a nurse is reviewing info about advance directives with a newly admitted client. which of the following statements by the client indicates an understanding of the teaching?

I have a living will that outlines my wishes when I am unable to make a decision

1. a nurse is planning a community education program about colorectal cancer. which of the following risk factors should the nurse identify as modifiable? (SATA)

a. Smoking

b. alcohol consumption

c. high-fat diet

1. a nurse is reviewing the lab report of a client who has been experiencing a fever for the last 3 days, what lab results indicates the client is experiencing FVD (fluid volume deficit)?

a. increased hematocrit

1. A charge nurse discovers that a nurse did not notify the provider that a client's condition had changed. the charge nurse should identify that the nurse is accountable for which of the following torts?

a. Negligence

1. A nurse is performing a cultural assessment of a group of clients to maintain respect for their value systems and beliefs. which of the following should the nurse identify as examples of cultural variables? (SATA)

a. eye contact

b. personal space

c. touch

1. A nurse is admitting a client who has recently developed fever, confusion, and a decreased level of consciousness. which of the following actions should the nurse take first after obtaining the client's history and assessment?

a. identify the client's needs

1. A nurse is planning to administer several meds to a client through a ng tube, which actions should the nurse take?

a. dissolve crushed tablet meds in sterile water (in 15-30 mL sterile water)

1. A nurse is preparing to perform a sterile dressing change for a client who has a surgical wound. which of the following actions should the nurse take to prevent contamination during the dressing change?

a. Restart the procedure if the sterile solution splashes onto the sterile field when pouring the solution into the dressing tray

1. a nurse is admitting a client who has meningococcal meningitis, what should the nurse do first?

a. initiate droplet precaution

1. A nurse is reviewing the health history of an OA who has a hip fracturethe nurse should identify what is a risk of developing pressure injuries?

a. urinary incontinence

1. a nurse is performing a focused assessment for a client who has dysrhythmias, what indicates ineffective cardiac contractions?

a. pulse deficit

1. A nurse is preparing to transfer a client from a chair to the bed. the client can bear partial weight and has upper body strength. which of the following devices should the nurse use to transfer the patient?

a. A stand-assist lift

1. a charge nurse is making assignments for the upcoming shift, what assignments should the charge nurse assign to an LPN?

a. a client who has dehydration and IBD (inflammatory bowel disease)

1. a nurse is caring for a client who has a prescription for a narcotic med, after admin the nurse is left with an unused portion, what should the nurse do?

a. discards the medication with another nurse as a witness

1. a nurse enters a client's room and sees smoke coming from the trash can. which of the following actions should the nurse take first?

a. evacuate the room

1. a nurse is caring for an OA who has a nonpalpable skin lesion that is less than 0.5cm (0.2in) in diameter. which of the following terms should the nurse use to document this finding?

a. Macule (nonpalpable smaller than 1cm, ex: freckle)

1. a nurse is caring for a client who has an indwelling urinary catheter, what should the nurse identify as a catheter occlusion?

a. Bladder distention

1. A nurse is teaching about foot care to a client who has DM, what statement indicates understanding?

a. I should wear my slippers whenever i am out of bed

1. a nurse is providing discharge teaching to a client who has a prescription for home oxygen therapy (O2), which info should the nurse teach?

a. Wear cotton socks when oxygen is in use

1. A nurse finds a client on the floor of their room experiencing a seizure, which of the following actions is the nurse's priority

a. Place the client on their sided with their head forward

1. A nurse is caring for a client who reports burning around the peripheral IV site, which finding should the nurse identify as a manifestation of infiltration?

Edema

1. a nurse is in an acute care facility is caring for a client who is postop following abdominal surgery. which of the following behaviors should the nurse identify as increasing the client's risk for constipation? (SATA)

a. urge suppression

b. history of chronic stimulant laxative use

c. inadequate fluid intake

1. a nurse is completing an admission assessment for a client who has hearing loss, what action should the nurse take?

a. Use written materials to assist with communication

1. a community health nurse is teaching a group of clients about first aid for different types of wounds. which of the following client statements indicates an understanding of the teaching?

a. I should apply clean dressings over the top of blood saturated dressings and hold pressure

1. a nurse is preparing a client for transfer to another unit? which finding does the nurse include in the transfer report? (SATA)

a. Response to pain medication

b. Review of ongoing discharge plan

c. Recent physical changes

1. A nurse is caring for a client who has dementia and frequently tries to get out of bed, which of the following actions should the nurse take? (SATA)

a. turn on the bed alarm

b. maintain the bed in the lowest position

c. encourage the family to stay with the patient

1. A nurse is caring for a patient who is scheduled for a cataract surgery, the client states "is see just fine and have decided to cancel my surgery". which of the following responses should the nurse make?

a. Share with me more about the thought that are concerning you

1. A nurse is sitting with the partner of a client who recently died. which of the following actions should the nurse take to facilitate mourning?

a. Encourage the partner to ask for help when needed

1. A nurse receives a report from assistive personnel that a client's BP is 160/95, what should the nurse do first?

a. Recheck the client's blood pressure