Fundamentals 2023 Proctor

A nurse is assisting with the care of a client who has a prescription for IV therapy. The client tells the nurse that he has numerous allergies. Which of the following allergies should the nurse bring to the attention of the charge nurse prior to the initiation of the therapy?

eggs

latex

seafood

bee stings

latex

A nurse is caring for a client who has a prescription for a high-protein diet to

promote wound healing following surgery. The client's religion prohibits eating

meat on particular days. Which of the following actions should the nurse take?

a. encourage the client to eat meat during this time to promote healing

b. advise the client to eat everything on the tray except the meat

c. suggest the client receive high-protein enteral feedings

d. ask the dietitian to recommend alternative food choices for the client

ask the dietitian to recommend alternative food choices for the client

A nurse is caring for a client who has prescription for a high-protein diet to promote wound healing following surgery. The client's religion prohibits eating meat on particular days. Which of the following actions should the nurse take?

Encourage the client to eat meat during this time to promote healing

Advise the client to eat everything on the tray except the meat

Suggest the client receive high-protein enteral feedings

Ask the dietitian to recommend alternative food choices for the clie

Ask the dietitian to recommend alternative food choices for the client

A nurse is collecting data from a client who is 2 days postoperative following a

colostomy. Which of the following findings should the nurse report to the

provider?

a purple-colored stoma

protrusion of the stoma

a small amount of bleeding from the stoma

intestinal gas in the pouch

a purple-colored stoma

A nurse is reinforcing teaching with a client about self-administration of

ophthalmic drops. Which of the following instructions should the nurse include?

"You will need to look to the side when you put the drops in your eye."

"You should put the drops directly in the center of your eyeball."

"You should cleanse your eye from the inner to the outer edge prior to putting in

the drops."

"You should avoid pressing on your tear duct after putting the drops in your eye."

"You should cleanse your eye from the inner to the outer edge prior to putting in

the drops."

A nurse is reinforcing teaching about carbohydrate counting with a client who has

a new diagnosis of diabetes mellitus. Which of the following actions should the

nurse take first?

a. use pictures of different food groups to help the client plan a daily menu

b. ask the client what he already knows about meal planning

c. give the client a brochure with sample menus for all meals

d. involve the family in the discussion of the client's meal plan

ask the client what he already knows about meal planning

A nurse is assisting with the admission of an adult client to a medical-surgical unit. Which of the following findings should the nurse identify as an indication that the client is malnourished?

heart rate 89/min

pink mucous membranes

pale, scaly skin

body mass index 23

pale, scaly skin

A nurse is reinforcing teaching about advance directives with a client who has end-

stage renal disease. Which of the following client statements indicates an

understanding of the teaching?

a. "I know that i can change my advance directives if I need to in the future."

b. "My health care proxy will make my health care decisions as soon as I have

signed the power of attorney."

c. "My family can overrule the decisions made by my health care proxy."

d. "Advance directives from one state are valid in any other state."

"I know that i can change my advance directives if I need to in the future."

A nurse is preparing a client for a Romberg test. Which of the following statements should the nurse make?

"Stand with your feet together and your arms at your sides."

"After I place the tuning fork, tell me when you no longer hear the sound"

"I'm going to stroke the lateral side of the bottom of your foot."

"Touch each fingertip as quickly as possible with your thumb."

"Stand with your feet together and your arms at your sides."

A nurse is contributing to the plan of care for a client who is dying. Which of the following interventions should the nurse recommend to include the client's family in the plan of care? (Select all that apply.)

keep the family updated about the client's status

Suggest the family members return home at night to allow the client to rest

encourage the family to comb the clients hair

tell the client's family what to expect as the client's death nears

ask the family to encourage the client to eat

keep the family updated about the client's status

A nurse is checking a client for a pulse deficit after detecting an irregular heart rate. Which of the following actions should the nurse take?

count the client's radial and apical pulses simultaneously with another nurse.

calculate the client's pulse for 30 seconds and multiply by 2

assist the client to a side-lying position

auscultate the area of the client's chest over the Erb's point

count the client's radial and apical pulses simultaneously with another nurse.

A nurse is reinforcing teaching with a client who is scheduled for a bladder scan. Which of the following instructions should the nurse include in the teaching?

"You will need to sign a consent form before we begin the procedure."

"I will place a gel pad directly above your pubic area before I place the probe."

"You will need to hold your urine for 1 hour prior to the procedure."

"You will receive a contrast dye through an IV catheter prior to the scan."

"I will place a gel pad directly above your pubic area before I place the probe."

A charge nurse is reinforcing teaching with a newly licensed nurse who is setting up a sterile field. Which of the following actions by the newly licensed nurse indicates an understanding of the teaching?

opening the first flap of a sterile package toward herself

dropping sterile gauze onto the field from a height of 7.5 cm (3 in)

removing and inverting a lid before placing it onto a nonsterile surface

maintaining the sterile field below waist level.

removing and inverting a lid before placing it onto a nonsterile surface

A nurse is caring for a client who has been vomiting excessively and has diarrhea. Which of the following findings should the nurse identify as an indication of fluid

volume deficit?

BUN 18 mg/dL

a bounding pulse

urine specific gravity 1.045

prominent neck veins

urine specific gravity 1.045

A nurse is providing care to four clients in an acute care setting. The nurse should identify that which of the following client statements presents and ethical dilemma?

"I might file a lawsuit because of how my surgery went."

"Please don't tell my doctor, but I am taking my partner's oxycodone."

"Please don't get me out of bed this morning. It hurts too much."

"I don't want to take my medicine. It makes me sick to my stomach."

"Please don't tell my doctor, but I am taking my partner's oxycodone."

A nurse is preparing to document information about a client's lower legs, which are swollen with 6 mm edema. Which of the following information should the nurse

document?

1+ pitting edema

2+ pitting edema

3+ pitting edema

4+ pitting edema

3+ pitting edema

A nurse manager is reinforcing teaching with a group of newly licensed nurses about the disclosure of client health information. The nurse can disclose health information without the client's written permission to which of the following

entities?

an insurance agency offering a life insurance policy

a family member who requests the client's diagnosis

a physical therapist who is involved in the client's care

an employer completing a pre-employment screening

a physical therapist who is involved in the client's care

A nurse is preparing to remove staples from a client's incision. Which of the following actions should the nurse take?

lift the staple remover when squeezing the handle

avoid completely closing the handle after squeezing

expect the staple to bed at each outer side of the staple

remove the staple from the skin after both sides are visible

remove the staple from the skin after both sides are visible

A nurse is reinforcing teaching with a client who has hypertension and a

prescription to measure her blood pressure daily. Which of the following client

statements indicates an understanding of the teaching?

a. "I will wait 15 minutes after drinking coffee to measure my blood pressure."

b. "I will measure my blood pressure while my arm is elevated above my heart."

c. "I should remove constrictive clothing prior to measuring my blood pressure."

d. I should measure my blood pressure immediately after eating breakfast."

"I should remove constrictive clothing prior to measuring my blood pressure."

A nurse is contributing to the plan of care for four clients. For which of the following clients should the nurse initiate airborne precautions?

a client who has pneumonia

a client who has measles

a client who has pertussis

a client who has methicillin-resistant Staphylococcus aureus (MRSA)

a client who has measles

A nurse is contributing to the plan of care for a client who practices Islam. Which of the following questions should the nurse ask the client to clarify her religious preferences?

"Do you receive Holy Communion?"

"Do you follow a kosher diet?"

"Do you consume pork products?"

"Do you oppose receiving a blood transfusion if it is needed?"

"Do you consume pork products?"

A nurse is reinforcing teaching with a client who has insomnia. Which of the following statements by the client indicates an understanding of the teaching?

"I should turn on the ceiling fan to block out unwanted noise."

"I will limit my daily nap to 45 minutes."

"I will drink a cup of green tea at bedtime to help me sleep."

"I should get out of bed if I don't fall asleep within an hour of lying down."

"I should turn on the ceiling fan to block out unwanted noise."

A nurse is caring for a client who has a new prescription for oxygen at 7 L/min via simple face mask. Which of the following actions should the nurse take to ensure client safety?

keep the side holes of the mask closed

ensure the reservoir bag is inflated on expiration

apply petroleum jelly to the clients nostils

attach a humidifier to the base of the flow meter

attach a humidifier to the base of the flow meter

A nurse is caring for four clients. For which of the following clients should the nurse use the therapeutic communication technique of silence?

a client who plans to leave the facility against medical advice

a client who informs the nurse that he has made his funeral arrangements

a client who tells the nurse that the night shift nurse did not bring his medication

a client who has just experienced the death of his child

a client who has just experienced the death of his child

A nurse is caring for a client who has an indwelling urinary catheter. Which of the following actions should the nurse take?

clean the perineal area at least once a day

empty the drainage bag when it is three-fourths full

flush the catheter with sterile water daily

disconnect the drainage bag when emptying and measuring urine

clean the perineal area at least once a day

A nurse is caring for a client who is receiving chemotherapy and has stomatitis. Which of the following actions should the nurse take to reduce the client's discomfort?

offer the client lemon-glycerin swabs

encourage the client to drink hot tea

use 0.9% sodium chloride solution to rinse the client's mouth

provide a commercial mouthwash for the client's oral care

use 0.9% sodium chloride solution to rinse the client's mouth

A nurse is reinforcing teaching with the partner of a client who is immobile. Which of the following instructions should the nurse give the partner about turning the client in bed?

"Keep your feet close together."

"Tighten your stomach muscles."

"Straighten your knees."

"Bend at your waist."

"Tighten your stomach muscles."

A nurse is caring for an older adult client and is concerned that the client may have a fecal impaction. Which of the following is the most important question for the nurse to ask?

"What types of foods have you been eating?"

"Are you using stool softeners or laxatives?"

"Have you been passing gas?"

"Have you had small liquid stools?"

"Have you had small liquid stools?"

A nurse is working in a hospital overhears the following conversation between two other nurses on the elevator. Which of the following actions should the nurse take?

inform the nurses that the neighbor's dog did not cause the wound

tell the nurses that this conversation is not appropriate

complete an incident report upon returning to the unit

report the nurses' conversation to the client's provider

tell the nurses that this conversation is not appropriate

A nurse is caring for a client who has chronic kidney disease. The nurse should identify that which of the following findings is the priority?

client reports voiding three times during the night

client reports burning and discomforting with urination

the client's WBC count is 11,000/mm^3

the client's output was 60 mL for the past 3 hr

the client's output was 60 mL for the past 3 hr

A nurse is planning to administer medication to a client who has a Clostridium difficile infection. Which of the following actions should the nurse plan to take to prevent the transmission of this infection to others?

Clean hands with an alcohol-based hand rub immediately after removing gloves.

Remove the cover gown in the client's room after providing care. Place the client in a room with negative-pressure airflow

Wear a mask when administering oral medications to the client.

Remove the cover gown in the client's room after providing care.

A nurse is reinforcing teaching with a client who is scheduled for a bladder scan. Which of the following instructions should the nurse include in the teaching?

"You will need to sign a consent form before we begin the procedure."

"I will place a gel pad directly above your pubic area before I place the probe."

"You will need to hold your urine for 1 hour prior to the procedure."

"You will receive a contrast dye through an IV catheter prior to the scan."

"I will place a gel pad directly above your pubic area before I place the probe."

A nurse is checking a client for a pulse deficit after detecting an irregular heart rate. Which of the following actions should the nurse take?

Count the client's radial and apical pulses simultaneously with another nurse.

Calculate the client's pulse for 30 seconds and multiply by 2.

Assist the client to a side-lying position.

Auscultate the area of the client's chest over the Erb's point.

Count the client's radial and apical pulses simultaneously with another nurse.

A nurse is preparing to obtain a clients vital signs. Which of the following actions should the nurse take when washing their hands?

Rinse their forearms with running water before applying soap.

Hold their hands above elbow level while washing and rinsing.

Generate a lather by rubbing their hands together vigorously for 5 seconds.

Turn off the faucet with a clean paper towel after drying hands.

Turn off the faucet with a clean paper towel after drying hands.

A nurse is preparing to perform a wound irrigation for a client who has a stage 3 pressure injury. Which of the following supplies should the nurse plan to use?

A piston syringe.

Barrier ointment.

Chilled irrigation solution.

Sterile cotton balls.

A piston syringe.

A nurse is caring for a client who has dyspnea caused by a respiratory infection. The nurse should assist the client into which of the following positions.

Orthopneic.

Dorsal recumbent.

Sims'

Prone

Orthopneic.

A nurse in reinforcing teaching about carbohydrate counting with a client who has a new diagnosis of diabetes mellitus. Which of the following actions should the nurse take first?

Use pictures of different food groups to help the client plan a daily menu.

Ask the client what they already know about meal planning.

Give the client a brochure with sample menus for all meals.

Involve the family in the discussion of the client's meal plan.

Ask the client what they already know about meal planning.

A nurse is caring for a client who has a new prescription for oxygen at 7 L/min via simple face mask. Which of the following actions should the nurse take to ensure client safety?

Keep the side holes of the mask closed.

Ensure the reservoir bag is inflated on expiration.

Apply petroleum jelly to the client's nostrils.

Attach a humidifier to the base of the flow meter.

Attach a humidifier to the base of the flow meter.

A nurse is contributing to the plan of care for a client who practices Islam. Which of the following questions should the nurse ask the client to clarify the client's religious preferences?

"Do you receive Holy Communion?"

"Do you follow a kosher diet?"

"Do you consume pork products?"

"Do you oppose receiving a blood transfusion if it is needed?"

"Do you consume pork products?"

A nurse is caring for a client who has limited mobility. Which of the following actions should the nurse take to maintain the client's skin integrity?

Use warm water when bathing the client.

Place a donut shaped cushion in the client's chair.

Massage reddened areas over bony prominences.

Maintain the client in high-Fowler's position.

Use warm water when bathing the client.

A nurse is caring for four clients. For which of the following clients should the nurse use the therapeutic communication technique of silence?

A client who plans to leave the facility against medical advice.

A client who informs the nurse that they have made their funeral arrangements.

A client who tells the nurse that the night shift nurse did not bring their

medication.

A client who has just experienced the death of their child

A client who has just experienced the death of their child

A nurse is caring for a group of clients in a long-term care facility. Which of the

following actions should the nurse take to prevent health care-associated infections

for these clients? (Select all that apply)

-Place immunocompromised clients in the same room.

-Wash hands after removing gloves.

-Use antimicrobial hand gel after refilling a client's water pitcher

-Clean the stethoscope with an antimicrobial wipe after obtaining vital signs.

-Administer a prophylactic dose of antibiotics prior to discharge.

-Wash hands after removing gloves.

-Use antimicrobial hand gel after refilling a client's water pitcher.

-Clean the stethoscope with an antimicrobial wipe after obtaining vital signs.

A nurse is caring for a client who has been vomiting and has diarrhea. Which of the following findings should the nurse identify as an indication of fluid volume deficit?

BUN 18 mg/dL.

A thready pulse.

Hemoglobin 15 g/dL.

Prominent neck veins.

A thready pulse.

A nurse is planning care for a group of clients. The nurse should expect to witness an informed consent for a client who will undergo which of the following procedures?

Administration of an enema.

Performance of a paracentesis.

Insertion of an indwelling urinary catheter.

Placement of an NG tube.

Performance of a paracentesis.

A nurse working in a community clinic is talking with an older client who states that their life has no purpose. The nurse should identify that the client is in which of the following stages of Erikson's Theory of Psychosocial Development?

Ego integrity vs. despair

Generativity vs. self-absorption

Identity vs. role confusion

Intimacy vs. isolation

Ego integrity vs. despair

A nurse is caring for a client who has chronic pain. The nurse recommends that the client concentrate on a memory of a pleasurable experience. Which of the following complementary therapies is the nurse suggesting?

Art therapy.

Tai chi.

Guided imagery.

Biofeedback.

Guided imagery.

A nurse is reinforcing teaching about advance directives with a client who has end-stage renal disease. Which of the following client statements indicates an understanding of the teaching?

"I know that I can change my advance directives if I need to in the future."

"My health care surrogate will make my health care decisions as soon as I have signed the power of attorney."

"My family can overrule the decisions made by my health care surrogate."

"Advance directive from one state are valid in any other state."

"I know that I can change my advance directives if I need to in the future."

A nurse is providing care to four clients in an acute care setting. The nurse should identify that which of the following client statements presents an ethical dilemma?

"I might file a lawsuit because of how my surgery went."

"Please don't tell my doctor, but I am taking my partner's oxycodone." "Please don't get me out of bed this morning. It hurts too much."

"I don't want to take my medicine. It makes me sick to my stomach."

"Please don't tell my doctor, but I am taking my partner's oxycodone."

A nurse is caring for a client who has a new diagnosis of cancer. Which of the following actions by the nurse maintains the client's confidentiality?

Sharing the client's prognosis with a member of the client's family.

Discussing the client's status with a member of the spiritual support team.

Collaborating with a nurse from another unit about the client's care.

Providing client information to another nurse at change of shift.

Providing client information to another nurse at change of shift.

A nurse and an assistive personnel (AP) are providing postmortem care for a decease client prior to visitation by the family. Which of the following actions by the AP requires intervention by the nurse?

Fathering the client's personal belongings.

Removing the client's dentures.

Placing absorbent pads under the client's buttocks.

Closing the client's eyes.

Removing the client's dentures.

A nurse reinforcing teaching with a client who has pneumonia and a productive cough. Which of the following instructions should the nurse include in the teaching?

"Your visitors should wear a protective gown."

"You should receive a pneumonia vaccine every year."

"You should stand 1 foot away from others when coughing."

"You should cover your mouth with a tissue when you cough."

"You should cover your mouth with a tissue when you cough."

A nurse is reinforcing teaching with the partner of a client who is immobile. Which of the following instructions should the nurse give the partner about turning the client in bed?

"Keep your feet close together."

"Tighten your stomach muscles."

"Straighten your knees."

"Bend at your waist."

"Tighten your stomach muscles."

A nurse is collecting data from a client who is 2 days postoperative following a colostomy placement. Which of the following findings should the nurse report to the provider?

A purple-colored stoma.

Protrusion of the stoma.

A small amount of bleeding from the stoma.

Intestinal gas in the pouch.

A purple-colored stoma.

A nurse is collecting data from a client who is 1 day postoperative following abdominal surgery. Which of the following findings is the priority for the nurse to report to the provider?

The client reports incisional pain as 7 on a scale of 0-10.

The client reports increased nausea and chills.

The client has an oral temperature of 38.5° (101.3° F).

The client has tenderness and warmth in their calf.

The client has tenderness and warmth in their calf.

A nurse is preparing a client for a Romberg test. Which of the following statements should the nurse make?

"Stand with your feet together and your arms at your sides."

"After I place the turning fork, tell me when you no longer hear the sound."

"I'm going to stroke the lateral side of the bottom of your foot."

"Touch each fingertip as quickly as possible with your thumb."

"Stand with your feet together and your arms at your sides."

A nurse is contributing to the plan of care for a client who is dying. Which of the

following intervention should the nurse recommend to include the client's family in

the plan of care? (Select all that apply.)

-Keep the family updated about the client's status.

-Suggest that family members return home at night to allow the client to rest.

-Encourage the family to comb the client's hair.

-Tell the client's family what to expect as the client's death nears.

- Ask the family to encourage the client to eat

-Keep the family updated about the client's status.

-Encourage the family to comb the client's hair.

-Tell the client's family what to expect as the client's death nears.

A nurse is caring for a client who reports difficulty sleeping at home. Which of the following recommendations should the nurse provide to promote a restful home sleep environment?

"Perform muscle relaxation before bedtime."

"Exercise vigorously 1 hour prior to going to bed."

"Drink a cup of hot chocolate at bedtime."

"Change the time you go to sleep each day.

"Perform muscle relaxation before bedtime."

A nurse is reinforcing teaching with a new parent who is concerned about sudden infant death syndrome (SIDS). Which of the following statements by the client indicates an understanding of the teaching?

"I will place my baby on her side to sleep."

"I should avoid giving my baby a pacifier."

"I will remove all stuffed animals from my baby's crib."

"I will cover my baby with a light blanket when she is sleeping."

"I will remove all stuffed animals from my baby's crib."

A nurse is providing oral hygiene for a client who is unconscious. Identify the sequence of the steps the nurse should take. (Move the steps into the box in order of performance)

-Place a towel under the client's head with an emesis basin under their chin.

-Assess the client's gag reflex.

-Cleanse the client's mouth using a toothbrush.

-Separate the client's upper and lower teeth with an oral airway device.

-Position the client on their side with their head turned to the side.

1. Assess the client's gag reflex.

2- Position the client on their side with their head turned to the side.

3- -Place a towel under the client's head with an emesis basin under their chin.

4- Separate the client's upper and lower teeth with an oral airway device.

5- Cleanse the client's mouth using a toothbrush

A nurse is caring for a client who is receiving intermittent enteral feedings. Which of the following is the first action the nurse should take?

Measure the client's gastric residual before each feeding.

Change the bag and tubing every 24 hours.

Document intake and output.

Flush the tubing with 30 mL of water after each feeding.

Measure the client's gastric residual before each feeding.

A nurse is in a long-term care facility in collecting admission data from a client who uses a hearing aid. Which of the following actions should the nurse take?

Sit beside the client.

Speak slowly and loudly.

Dim the lights in the client's room.

Choose a private room for the interview.

Choose a private room for the interview.

A nurse manager is reinforcing teaching with a group of newly licensed nurses about the disclosure of client health information. A nurse can disclose health information without the client's written permission to which the following entities?

An insurance agency offering a life insurance policy.

A family member who requests the client's diagnosis.

A physical therapist who is involved in the client's care.

An employer completing a pre-employment screening.

An employer completing a pre-employment screening.

A nurse is demonstrating the use of a transparent film dressing over a client's superficial wound. Which of the following information about a transparent film dressing should the nurse include?

"This dressing keeps the wound bed dry."

"This dressing allows the wound bed to breathe."

"This dressing requires a secondary dressing."

"This dressing requires paper tape to secure."

"This dressing allows the wound bed to breathe."

A nurse is collecting data from a client following a lumbar puncture. The nurse should identify which of the following findings as a potential adverse effect of this procedure?

Fluid Overload

Diarrhea

Headache

Difficulty voiding

Headache

A nurse is evaluating the crutch-walking technique of a client who is required to keep weight off their right leg. Which of the following is the proper crutch gait for this client?

Four-point

Three-point

Two-point

Swing-through

Three-point

A nurse assisting with the admission of a client to a medical-surgical unit. Which of the following findings should the nurse identify as an indication that the client is malnourished?

Heart rate 89/min.

Pink mucous membranes.

Pallor with scaly skin.

Body mass index 23

Pallor with scaly skin.

A nurse is caring for a client who has an indwelling urinary catheter. Which of the following actions should the nurse take?

Clean the perineal area at least once a day.

Empty the drainage bag when it is three-fourths full.

Flush the catheter with sterile water daily.

Disconnect the drainage bag when emptying and measuring urine.

Clean the perineal area at least once a day.

A nurse is caring for a client who is postoperative following a mastectomy. The client states, "I can barely look at myself in the mirror." The nurse should identify that the client is experiencing which of the following?

Complicated grief.

Maturational loss.

Disenfranchised grief.

Actual loss.

Actual loss.

A nurse is caring for a client who is scheduled for surgery the following day. During the night, the client is unable to sleep and is restless. Which of the following statements should the nurse make?

"It must be difficult facing this type of surgery."

"Other clients who have had this surgery have done just fine."

"This facility is known for providing excellent care for people who need this type of surgery."

"I can request a sleeping pill, if you think that will help."

"It must be difficult facing this type of surgery."

A nurse is caring for a client who reports itching 30 min after receiving a newly prescribed medication. Which of the following data should the nurse document in the client's medical record?

Client is itching from medication.

Client states, "I started to itch after taking that medication."

It appears that the client has a rash from the medication.

Rash from medication noted.

Client states, "I started to itch after taking that medication."