Foundations OA q's

A child has experienced several episodes of vomiting. After the nurse reviews the need to provide only clear liquids, the parent of the child reports making clear liquid popsicles out of flavored gelatin for the child. Which information should the nurse obtain about the popsicles?

Whether they contain pulp or fruit.

The nurse is caring for a client with type 2 diabetes mellitus who had surgery for a large bowel resection with a colostomy placement. The client has now developed hyperglycemia which require self injections of insulin after discharge. When designing the postoperative plan of care, which outcome statement should the nurse use?

The client will adhere to the medication regimen after discharge.

A 16-year-old emancipated client is being seen in the emergency department following a minor automobile accident. The client's parents arrive and are asking questions about the client's laboratory results. Which response is best for the nurse to provide?

"I can only give medical Information to your child because they are legally an adult."

The nurse is caring for a client with a history of neuropathy who reports increasing numbness and tingling in the lower extremities. Which problem should the nurse determine is the priority for promoting foot care at this time?

Risk for impaired skin integrity

The nurse enters a client's room to perform a physical assessment and finds the client crying. Which response is best for the nurse to provide?

"While touching the client's forearm, asks, "Would you like to talk about it?"

The nurse is interviewing a client with lower abdominal pain and dysuria, and needs to question the client about sexual activity. Which approach is best for the nurse to use?

Begin with questions that are less sensitive in nature.

The nurse is using guided imagery with a client who is experiencing chronic pain. The nurse should direct the client's attention on which focus?

Positive external places.

The nurse is caring for a client one week postsurgery. Which finding should the nurse expect to see if the surgical incision is healing properly?

A well approximated Incision site.

After completing daily charting at 1400, the nurse realizes that a 0900 occurrence was not entered. Which is the best way for the nurse to enter computer documentation of the 0900 occurrence?

Make an electronic addendum following the 1400 documentation.

The nurse is teaching a client how to do active range of motion (ROM) exercises. To exercise the hinge joints, which action should the nurse instruct the client to perform?

Bend the arm by flexing the ulnar to the humerus

The nurse observes the unlicensed assistive personnel (UAP) securing a client's wrist restraints to the bedside rails. Which action is most important for the nurse to implement?

Demonstrate proper securing of the restraints.

The nurse is assessing a client who is having pain of the right upper abdominal area. To assess the quality of the client's abdominal pain, which approach should the nurse use?

Ask the client to describe the pain.

The nurse is caring for a client who is postoperative and receiving supplemental oxygen at 2 L/minute via nasal cannula. The oxygen saturation is 89%. Which action should the nurse implement?

Verify placement of pulse oximeter

The nurse is teaching the client to self administer a dose of low molecular weight heparin SUBQ. Which instruction should the nurse Include?

Inject In abdominal area at least 2 in (5.1 cm) from the umbilicus.

The healthcare provider prescribes a 24 hour urine specimen to be collected for creatinine clearance. The client is eager to go home and tells the nurse that the first sample was put in the urinal 2 hours ago. Which action should the nurse implement?

Start collecting the specimen with the next void.

The nurse in a skilled nursing facility observes a colleague leaving printed electronic medical record (EMR) copies of a client unattended on a counter top. Which action should the nurse implement?

Communicate the colleague's activities to the unit charge nurse.

A healthcare organization requires nurses to chart by exception. Which assessment should the nurse document?

Basilar lung sounds that are diminished in the left lung

When assessing a client with a serum potassium level of 7.5 mEq/L (7.5 mmol/L), which intervention is most important for the nurse to implement?

Reference Range: Potassium [3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L)]

Determine apical pulse rate and rhythm.

An unlicensed assistive personnel (UAP) is assigned to feed a client who has received a prescription to institute droplet precautions for a bacterial meningitis infection. The UAP requests a change in assignment, reporting having not yet been fitted for a particulate filter mask. Which action should the nurse take?

Instruct the UAP that a standard face mask is sufficient to be able to provide care for the assigned client.

The nurse is preparing to administer lorazepam 1.5 mg IV to an anxious preoperative client. The medication is available in a 2 mg/mL. vial. Which action should the nurse perform with the remainder of the medication?

Ask another nurse to witness the medication being discarded.

A client with chronic fecal Incontinence is crying because of being embarrassed for not getting to the bathroom in time to avoid soiling the bed and clothing. When establishing a bowel training regimen, which Intervention should the nurse Implement?

Assist to a bedside commode 30 minutes after meals.

A confused older adult client is having trouble sleeping at night and is sometimes found wandering in the hallway. Which nursing intervention should the nurse implement first?

Provide a back rub at bedtime.

The nurse is reviewing the admission assessment of a client with chronic pain. What Intervention(s) should the nurse Include in the client's plan of care? Select all that apply.

Assist the client to ambulate as much as possible during waking hours.

Determine client's subjective measure of pain using a numerical pain scale.

Provide comfort measures such as topical warm application and tactile massage.

Implement a 24 hour schedule of routine administration of prescribed analgesic.

The nurse educator is conducting a class for unlicensed assistive personnel (UAP). Which action Indicates that a UAP understands gloving procedures?

Puts on new gloves when entering a client's room.

An older adult female client tells the clinic nurse about frequently awakening during the night and not being able to go back to sleep. What action(s) should the nurse suggest to the client to help improve sleep? Select all that apply.

Avoid drinking caffeinated beverages late in the day.

Establish a regular time for going to bed and getting up.

The nurse notices a client grimacing while moving from the bed to a chair, but when asked about the pain the client denies having any pain. Which intervention should the nurse implement first?

Ask the client what is causing the grimacing

The nurse attaches a pulse oximeter to a client's finger and obtains an oxygen saturation reading of 91%. Which assessment finding most likely contributes to this reading?

2+ edema of fingers and hands

The nurse observes a newly employed unlicensed assistive personnel (UAP) checking the temperature of an adult client using a tympanic thermometer. The UAP pulls the client's auricle up and back and prepares to Insert the thermometer. Which action should the nurse implement?

Use positive reinforcement to affirm that the procedure is being performed correctly.

When providing health teaching to older adult clients, which action is most important for the nurse to implement?

Use everyday language when explaining issues

The nurse is obtaining a systolic blood pressure by palpation. While inflating the cuff, the radial pulse is no longer palpable at 90 mm Hg. Which action should the nurse take?

Inflate blood pressure cuff to 120 mm Hg

The nurse is assessing a client who reports a 3 day history of vomiting and diarrhea and experiencing difficulty in tolerating oral fluids. Which urine specific gravity value would the nurse expect to see on Initial testing?

Reference Range: Urine Specific Gravity [1.005 to 1.03]

1.035:

This specific gravity value indicates highly concentrated urine; indicative of significant dehydration.

The nurse is teaching a client about use of syringes and needles for home administration of medications. Which action by the client indicates an understanding of standard precautions?

Washes hands before handling the needle and syringe.

A nurse administers an opioid analgesic to a postoperative client who also has severe obstructive sleep apnea (OSA). Which Intervention is most important for the nurse to implement before leaving the client alone?

Apply the client's positive airway pressure device.

The nurse plans to use the Situation, Background, Assessment, and Recommendation (SBAR) format of communication during which interaction?

Reporting a change in a client's condition to the healthcare provider.

The nurse observes an unlicensed assistive personnel (UAP) feeding a client who had a cerebral vascular accident (CVA) and is at risk for aspiration. Which action by the UAP should the nurse recognize indicates the need for additional teaching?

Allows 30 minutes of rest before feeding.

The nurse is teaching a client about a newly prescribed medication. To confirm that the client is learning the critical information, which strategy is most important for the nurse to include during the instruction?

Ask the client for learning feedback.

The nurse uses a sterile syringe to obtain a urine specimen from a client's indwelling urinary catheter. After placing the specimen in a biohazard bag, the nurse transports the specimen to the laboratory. During which part of this procedure should the nurse wear gloves?

Using the syringe to remove the specimen from the catheter.

A client receives a prescription for dextromethorphan 30 mg every 6 to 8 hours PO as needed for cough. The bottle is labeled "Dextromethorphan for Oral Suspension, USP 30 mg per 15 mL." How many tablespoons should the nurse instruct the client to take with each dose? (Enter numerical value only.)

1

A client who is paraplegic is admitted with a foul smelling drainage from a sacral ulcer. The client is suspected to have a methicillin resistant Staphylococcus aureus (MRSA) infection. Which nursing intervention(s) should the nurse include in the plan of care? Select all that apply.

Institute contact precautions for staff and visitors.

Send wound drainage for culture and sensitivity.

Monitor the client's white blood cell count.

A client is admitted to the rehabilitation unit following a cerebrovascular accident (CVA), which resulted in paralysis of the right arm. When the nurse enters the room, the client is struggling to put on a shirt, and curses at the nurse. Which response is best for the nurse to provide?

"Dressing must be a frustrating experience for you."

A hospitalized client who has an advance directive and healthcare power of attorney is receiving enteral nutrition through a nasogastric (NG) tube. The client vomits and appears to be choking. Which action should the nurse take?

Stop the feeding

The nurse is demonstrating three point gait crutch walking to an older adult client who broke a foot while playing soccer with the grandchildren. Which behavior Indicates that the client understands proper crutch walking?

Progresses to foot touchdown and weight bearing of affected leg.

A nurse stops at a motor vehicle collision to provide help for a victim who is trapped in an overturned running vehicle. The nurse turns off the engine key, and asks the client to wiggle the fingers because the client's head is impinged on the roof and the neck is bent to the left shoulder. After Emergency Medical Services (EMS) arrive, the nurse reports that the victim is conscious, but is not able to talk, and then the nurse leaves the scene. Which legal action can be taken in this situation?

Good Samaritan immunity.

The nurse assesses an older adult client's ability to perform activities of daily living (ADLs). When observing the client ambulate, the nurse notes that the client's posture is upright, and the gait is smooth and steady. Which action should the nurse take next?

Determine the client's activity tolerance

A client who had emergency gallbladder surgery yesterday is getting ready for discharge. The client speaks very little English. When teaching wound care, which method should the nurse use to evaluate the client's understanding of self care at home?

Have the client demonstrate prescribed wound care

The nurse is preparing to give an emergency sedative injection to an agitated client. Which action by the nurse comprises a tort?

Placing a client in restraints without having a healthcare provider's order.

Which client assessment should the nurse perform during nasopharyngeal suctioning?

Observe the client's skin and mucous membranes.

A client with a family history of cardiac disease is seeking information to control risk factors. Which lifestyle modification is most important for the nurse to encourage?

Smoking cessation.

When assuming care of a client at 1900, the nurse learns in report that a client with a urinary tract infection had an indwelling urinary catheter removed during the previous shift. Which information is most important for the nurse to obtain?

When the client voided following catheter removal.

The healthcare provider prescribes streptomycin 200 mg IM every 12 hours. The vial is labeled, "Streptomycin 1 gram/2.5 mL." How many milliliters should the nurse administer? (Enter numerical value only. If rounding is required, round to the nearest tenth.)

0.5

The nurse observes a practical nurse (PN) performing oral care on an unconscious client. Which action by the PN indicates to the nurse the need for additional training?

Places the client in a supine position.

A client tells the nurse about starting an aerobic workout program to lose weight and help with insomnia. The client states that it still takes over an hour to fall asleep at night. Which action should the nurse implement?

Ask the client to describe the exercise schedule that he has been following.

A client is admitted with reports of shortness of breath, dyspnea on exertion, and chest pressure. The healthcare provider prescribes a medication that is unfamiliar to the nurse. When checking the drug handbook, the nurse reads that the prescribed amount is an unusually large dose. Which action should the nurse take?

Verify the prescribed dosage with healthcare provider.

The nurse is inserting a urinary catheter that has been prescribed for the client. When the tip of the catheter reemerges from the insertion site, which action should the nurse take next?

Obtain a new catheter.

A client is in contact isolation due to a stage IV coccyx wound infected with methicillin resistant Staphylococcus aureus (MRSA). The nurse plans interventions to prevent multiple re-entries to the client's room. In which order should the nurse perform the interventions?

Restart the IV line, perform tracheostomy care, change coccyx dressing.

Skin damage w/ NG tube on what parts

Cheeks and upper ear

Patient with soft, light colored stool and occult blood in stool

Collect sample and proceed

Male patient who is uncircumcised would be cleaned

Clean meatus with circular motion

Priority for a female vag. bleeding

Safe sex protection

Bow tie : Patient with laceration to liver, fractured rib, femur fused

Isometric exercise - quad flexing, hold for 10 sec, repeat 8-10x

One of the bowtie options was ATELECTASIS, but not sure if its correct

air sacs (alveoli) collapse → less gas exchange
post-op patients
S/S:

• ↓ O2 saturation

• dyspnea (shortness of breath)

• diminished breath sounds

• crackles
  Interventions:
  incentive spirometer ⭐

• deep breathing

• coughing

• early ambulation

Change their cannula to face mask for accuracy as an action!

oxygen?

In a MRSA biohazard bag its...

SPUTUM

The client who is now sad after visiting with significant other...

Ask what happened with their visit with significant other.

Role playing is for...

Adolescents

Nurse should wear...

goggles

Prodromal...

prevent infection

Hypoxia bowtie...

Pneumonia

sexual dysfunction =

hypotension drugs

Diabetic incontinence

monitor blood glucose, pain, skin care

offer sip of water for...

NG tube gag

>150 residual = (greater than 150)

risk for infection

For female catheters...

advance an inch

For soft restraint...

check pulse distal to restraint

"Bedfast" client...

put them on their side

EHR is....

remind about information security

The client is a 60 four-year-old female. With a 3 day history of cough and fun chest paint. She recently began to have difficulty breathing. Cardiac causes of chest pain were ruled out with the laboratory tests. The client will be admitted for presumed pneumonia. The client has a history of it of type 2 diabetes. Melitis, she takes insulin glarging. Twelve units in the morning and ten units in the evening

What medication error prevention techniques would have helped to avoid this error select all that apply

Document all medication and the electronic record as soon as it is given

Involve and educate clients in medication administration.

In planning the turning schedule for a bedfast client. It is, it's most important for the nurse to consider which assessment finding?

A brayden risk assessment scale rating score of ten

The mother of 2 toddlers, who was recently divorced, is scheduled for breast augmentation during the day surgery admission process. The client tells the nurse that she has not executed it. A living will, but does not want to be resuscitated. Or put on any mechanical breathing day machines, which actions should the nurse take?Select all that apply

Explain the benefit of executing an advanced directive document.The client's statement on the admission form

A client diagnosed with primary open angle. Glaucoma received a problem prescription for mayotic eye drops. Which instructions should the nurse plan to include in this clinton's teaching?

Do not allow the dropper bottle to touch the eye

The client is a two-year-old female with diarrhea and dehydration. She was born at 32 weeks. It's vaginally and was in the neo. Natal intensive care unit n I c u for several weeks before being discharged home.She is developmentally appropriate.

Which medication error prevention techniques would have helped to avoid this error select all that apply

Double checkThe dosage of high risk medications with another nurse

Use at least two client identifiers before administering a dose

Involve and educate clients in medication administration

What action should the nurse implement?When inserting an indwelling catheter for an uncircumcised male client

Clean the urinary meatus before retracting the foreskin

A client is being discharged post surgery, which information provided by the client requires additional instruction by the nurse?

Call the pharmacy to see which medications should be taken.