D439 Foundations of Nursing OA Approval Q & A (Copy)

The nurse is caring for four clients. The client with which clinical manifestation requires immediate attention from the nurse?

Respiratory rate of 25 breaths per minute after resting for 3 minutes after activity

The nurse places a client who had abdominal surgery in the semi-Fowler position. The client states, "I prefer to lie flat when in bed. I feel like I am almost sitting up." Which is an appropriate response by the nurse?

"Lifting your chest above your abdomen facilitates drainage in your wound drains."

The nurse is educating a client who has just been prescribed a diuretic about how to safely perform activities of daily living. Which statement should the nurse include in the teaching

Change positions slowly to minimize orthostatic hypotension

The nurse recognizes that which statements made by a patient indicate an understanding of behaviors that will promote sleep? (Select all that apply.)

"I will not watch television in bed."

"I will not drink caffeine later in the day."

"I will start to exercise regularly during the day."

Your patient is being discharged home and will be required to self-administer injectable Heparin. You are observing the patient administer their scheduled dose of Heparin to confirm that the patient knows how to do it correctly. What action by the patient requires you to re-educate them about how to administer Heparin?

The patient injects the needle 1 inch away from the umbilicus

A nurse caring for patients in a long-term care facility is often required to collect urine specimens from patients for laboratory testing. Which techniques for urine collection are performed correctly? Select all that apply.

The nurse collects about 3 mL of urine from a patient's indwelling catheter to send for a urine culture.

The nurse discards the first urine of the day when performing a 24-hour urine specimen collection on a patient.

The nurse is caring for a 60-year-old client with a diagnosis of C-diff and is incontinent who requires frequent linen changes. What should the nurse be most concerned for

Impaired skin integrity

The nurse is making an occupied bed. Which nursing action is most important

Ensuring that the client's head is supported and is in functional alignment

When giving a client a bed bath, a nurse washes the client's extremities from distal to proximal. Which of the following rationales best supports this nursing action?

Stimulates Venous return

The nurse is caring for a debilitated female client with nocturia. Which nursing intervention is the priority when planning to meet this client's needs

Positioning a bedside commode near the bed

The nurse plans to teach a client with hemiparesis to use a cane. Which should the nurse teach the client to do? Select all that apply.

Hold the cane in the strong hand when walking

The nurse is caring for a group of clients in the post anesthesia care unit. Which response by a client in the post anesthesia care unit is the priority concern for the nurse?

Reduced level of consciousness

The nurse is meeting a client for the first time. Which should the nurse do during the orientation phase of this therapeutic relationship?

Build rapport

A nurse discovers that a client is taking natural herbal remedies. Which intervention is most important for the nurse to do?

Communicate the supplement use to the primary health-care provider

Which condition places a client at the highest risk for developing an infection?

Burns over more than 20% of the body

The nurse is caring for a group of clients experiencing various medical conditions. Which condition places the client at the highest risk for a wound infection?

Puncture of the foot by a nail

When collecting a 24-hour urine specimen for creatinine clearance, it is MOST important for the nurse to do which of the following?

Ask if a preservative is present in the container.

Your patient will be using crutches for mobility. After educating the patient on how to adjust the crutches to fit correctly, you assess how well the patient understood the instructions. What findings demonstrate that the crutches were adjusted correctly by the patient? Select all that apply

When the patient grips the hand grips of the crutches the elbow bends at about 30 degrees.

The patient has a 2-3 finger width distance between the axillae and crutch rest pad

Why is a client with fever often predisposed to pressure ulcers?

Increased metabolism causes increased oxygen needs that cannot be met

Which of the following are primary risk factors for pressure ulcers? Select all that apply

Low-protein diet

Lengthy surgical procedures

Fever

A client has thick, tenacious respiratory secretions. Which should the nurse do to liquefy the client's respiratory secretions?

Encourage the client to drink more fluid

An unconscious client who had oral surgery is admitted to the post anesthesia care unit. In which position should the nurse place the client?

Lateral

An emancipated minor is willing to participate in a clinical trial for a new drug. Whose signature is required on the informed consent form before the minor can participate in the trial?

The emancipated minor

When the nurse is administering medication to a confused client, the client says, "This pill looks different from the one I had before." Which should the nurse do first?

Check the original medication prescription

The primary health-care provider prescribes oxygen via a simple face mask at a flow rate of 6 liters. The nurse explains the procedure to the client and maintains standard precaution. Place the following steps in the order in which they should be implemented.

1) Attach the flowmeter to the wall oxygen source.

2) Attach the prefilled humidifier to the flowmeter.

3) Attach the face mask tubing to the humidifier

4) Place the mask on the client's face from the bridge of the nose to under the chin

5) Secure the elastic bands around the back of the client's head.

6) Turn the oxygen flowmeter on to 6 liters.

An anxious client repeatedly uses the call bell to get the nurse to come to the room. Finally, the nurse says to the client, "If you keep ringing, there will come a time when I won't answer your bell." Which legal term is related to this statement?

Assault

A client's wound is draining thick yellow material. The nurse correctly describes the drainage as:

Purulent

A nurse is caring for patients with variety of wounds. Which wound will most likely heal by primary intention?

Cut in the skin from a kitchen knife

A mother whose young daughter has died of leukemia is crying and is unable to talk about her feelings. Which is the best response by the nurse?

"It must be hard to deal with such a precious loss."

Which statement would best explain the role of the nurse when planning care for a culturally diverse population? The nurse will plan care to:

Provide care while aware of one's own bias, focusing on the client's individual needs rather than the staff's practices.

When signing a form as a witness, your signature shows that the client

Has signed that form and the witness saw it being done.

The nurse is providing instructions to a Chinese American client about the frequency and dosages of the take-home medicines. When conducting the teaching, the client continuously turns away from the nurse. The nurse should do which of the following appropriate actions

Continue with the instructions, then confirming the client's understanding

The primary health-care provider prescribes crutches for a person who has a left lower leg injury. The nurse is teaching the person how to move from a standing to a sitting position in a chair. Place the following steps in the order in which they should be implemented.

1) While standing, back up so that the unaffected leg is against the edge of the center of the chair seat

2) Hold the hand bars of both crutches with the left hand.

3) Grasp the arm of the chair with the right hand

4) Lean forward slightly and flex the knees and hips.

5) Lower the body slowly into the chair.

When teaching a female patient how to take a sublingual tablet, the nurse should instruct the patient to place the tablet on the:

Floor of the mouth

A male client on prolonged bed rest has developed a pressure ulcer. The wound shows no signs of healing even though the client has received skin care and has been turned every 2 hours. Which factor is most likely responsible for the failure to heal?

Inadequate protein intake.

The nurse is preparing to take vital signs in an alert client admitted to the hospital with dehydration secondary to vomiting and diarrhea. What is the best method used to assess the client's temperature

Axillary

A postoperative client has been placed on a clear liquid diet.Which items is the client allowed to consume. Select all that apply:

Broth

Coffee

Gelatin

Popsicle

A nurse is assessing the blood pressure of a client diagnosed with primary hypertension. The nurse ensures accurate measurement by avoiding which of the following

Taking a blood pressure within 15 minutes after nicotine or caffeine ingestion.

A nurse finds that a terminally ill patient has cold, clammy, and wax-like skin. What should the nurse infer from this assessment

The patient is likely to die soon.

The joint commission issues a guidelines regarding the use of restraints. In which case is a restraint properly used?

The nurse ensures that two fingers can be inserted between the restraint and the patient's ankle

A nurse instructor is teaching a class of student nurses about the nature of pain. Which statements accurately describe this phenomenon? Select all that apply.

Pain exists whenever the person experiencing it says it exists

Pain that occurs without a known cause is psychological in nature.

Pain is classified by duration, location, source, transmission, and etiology.

The nurse is caring for a client with advanced heart failure on an inpatient hospice unit. the client is having trouble breathing. which comfort intervention should the nurse implement first?

Elevate the head of bed

To allow adequate ventilation and oxygenation during nasopharyngeal suctioning, which action should the nurse take?

Allow adequate time between suctioning passes

What does SBAR stand for?

Situation, background, assessment, recommendation

A nurse is providing range-of-motion exercises for a 53-year-old female patient who is recovering from a stroke. During the session, the patient complains that she is "too tired to go on." What would be priority nursing actions for this patient? Select all that apply

Stop performing the exercises.

Re-evaluate the nursing plan of care

Assess the patient for other symptoms.

Isotonic, isometric, and resistive isometric are three categories of exercise. They are classified according to the type of muscle contraction involved. of the following exercises, which are considered isotonic?

Bicycling, swimming, walking, jogging, dancing

The nurse has documented that a patient has had two episodes of steatorrhea, which means that the character of the stool is:

Frothy and foul smelling

A patient returning to the nursing unit after knee surgery is verbalizing pain at the surgical site. The nurse's first action is to:

Assess the characteristics of the pain

A nurse is monitoring bowel elimination of a patient who has a history of constipation. The nurse implements measures to assist with bowel elimination if the patient has not had a bowel movement within how many days?

3

A nurse is providing care based on Maslow's hierarchy of basic human needs. For which of the following nursing activities is this approach useful?

Establishing priorities of care