Kaplan Fundamentals C NGN

The nurse provides care for a client with a nasogastric (NG) tube. Which assessment by the nurse is the most reliable indication the NG tube is correctly positioned?

1. Auscultate for bowel sounds.

2. The NG aspirate fluid has a pH of 3.

3. Marks on the tube are visible outside the nares.

4. The NG aspirate fluid is watery and green.

2. pH of 3

A client receives a prescription for a low-fat diet. Which food does the nurse encourage the client to eat? (Select all that apply.)

1. Whole milk and other milk products.

2. Skinless fish and poultry.

3. Fruits and plain vegetables.

4. A small portion of nuts.

5. Hot oatmeal or brown rice.

2,3,4,5

The nurse observes a staff member enter a client's room wearing a fit-tested N95 type respirator mask. The nurse questions this action if the staff member is caring for which client?

1. A client diagnosed with mumps.

2. A client diagnosed with varicella.

3. A client diagnosed with active tuberculosis.

4. A client diagnosed with measles.

1. Mumps

The nurse instructs a client with poor dental hygiene on actions to improve oral care. Which client statement indicates to the nurse that teaching is effective?

1. "I should see a dentist once a year."

2. "I should use dental floss once a week."

3. "I should use non-alcohol based mouthwash."

4. "I should brush my teeth before going to bed.

3. Non alcohol mouthwash

The nurse provides care for a client with a body mass index (BMI) of 18 kg/m2 . Which is the best description of the client's body weight?

1. Obese. 2. Normal weight. 3. Overweight. 4. Underweight.

4. Underweight

A client who was in a motor vehicle accident removes contact lenses a day later. Which potential health problem should the nurse observe this client?

1. Cataract. 2. Glaucoma. 3. Corneal abrasion. 4. Macular degeneration

3. Corneal Abrasion

The nurse obtains a health history from an older adult client. Which statement does the nurse expect the client to make?

1. "I get fewer urinary tract infections than I did before."

2. "My appetite is so much better than it used to be."

3. "I think that I am a little shorter than I used to be."

4. "I get so warm I need to wear lighter clothing."

3. Shorter

The nurse provides care for a client who reports back pain from a motor vehicle crash. The client needs to urinate and asks the nurse for the bedpan but is reluctant to move. Which action by the nurse is correct?

1. Have the client push on heels and lift buttocks off the bed for the nurse to place bedpan.

2. Advise the client that it is easier to get up and use the bedside commode.

3. Log-roll the client to the side, and use a fracture type bedpan.

4. Tell the client the health care provider will prescribe an indwelling urinary catheter.

3. Log rolling

The nurse is preparing a client for surgery. What is the nurse's responsibility regarding informed consent for the surgery?

1. Explaining all the risks and benefits of the surgery.

2. Answering any questions the client has about the surgery.

3. Ensuring the consent form is signed and attached to the client's record.

4. Suggesting alternatives to the procedure

3. Consent form signed

The nurse provides care for a client who is on bed rest for an acute illness. Which action does the nurse implement when providing range-ofmotion exercises for this client?

1. Begin at the head, completing one side at a time.

2. Begin with the extremity that causes the least discomfort.

3. Begin with the extremities, completing the arms before the legs.

4. Begin with the neck and shoulders to relax the client for the other exercises.

1. Head, one side at time

A client with a diagnosis of ovarian cancer experiences severe pain. Which principle does the nurse remember when caring for this client?

1. Caution must be used to prevent narcotic addition.

2. Cancer pain is mostly psychological and is unable to be completely controlled.

3. Pain medication should be given when the client exhibits physical signs of pain.

4. Pain medication is more effective if given before pain becomes severe.

4. Pain meds before severe

Which outcome indicates successful care of the client? (Select all that apply.)

1. Client is alert, talking with nurse about family coming to visit.

2. Temperature 99.7°F (37.6°C).

3. Urine is present in the collection bag.

4. Correct placement of the tube is confirmed with an X-ray.

5. The NG tube is determined to be patent with a flush of 30 mL of water.

6. Client states understanding of need for keeping head of bed elevated.

7. The physician has written an order for Fowler position.

8. The NG tube is secured to the client's face and gown.

1,2,4,5,6,7,8

Moist-to-dry dressing changes are prescribed for a client. After the first layer of dressing is removed, the client yells at the nurse, "Ouch, that really hurts. Are you sure you're doing it right?" Which statement is the best response by the nurse?

1. "I know it hurts and I am really sorry to have to do it, but sometimes things have to hurt before they get better."

2. "I'm peeling away the dead tissue. It hurts more the first time. Next time will be more comfortable, I promise."

3. "Yes, I'm doing it right. The dead tissue is supposed to stick to the dry dressing."

4. "I'm sorry this hurts. I will add some normal saline to loosen it a bit more."

4. Im sorry it hurts.

Which information does the nurse include in teaching sessions for a client prescribed a low-fat diet?

1. "A low-fat diet improves cardiovascular health."

2. "A low-fat diet lessens the risk for osteoporosis."

3. "A low-fat diet normalizes glucose levels."

4. "A low-fat diet enhances insulin resistance.

1. Low fat CV health

The nurse provides care for clients in a long term care facility. Which client indicates a need for the nurse to reinforce teaching about the use of assistive devices? (Select all that apply.)

1. The client uses a swing-through crutch gait to prevent weight bearing on the affected leg.

2. The client places weight on the axilla when taking a step using crutches.

3. The client lifts the walker, moves it forward then walks between the legs of the walker.

4. The client places a cane in the hand on the side of the affected leg.

5. The client uses a four-point crutch gait with no weight bearing on the affected leg.

6. The client uses a three-point crutch gait to prevent weight bearing on the affected leg.

2,4,5

The nurse prepares an adolescent client for a magnetic resonance imaging (MRI) procedure of the cervical spine. Which client statement causes the nurse to contact the health care provider?

1. "I just had a lunch with my family."

2. "I don't like closed spaces, but I will be all right."

3. "I have a lot of metal in my legs from the accident."

4. "Listening to music will help me relax in the machine."

3. Metal in legs

An adult client comes to the emergency department after puncturing a foot with a dirty, rusty nail. The client states the last tetanus vaccination (Td) was 6 years ago. Which action does the nurse take first?

1. Administer tetanus toxod (Td).

2. Determine how many tetanus immunizations the client has received.

3. Administer tetanus immune globulin (TIG).

4. Monitor for lockjaw

2. Determine tetanus immunizations received.

A client waiting for the results of a breast biopsy sits in the waiting room crying. Which statement from the nurse is therapeutic?

1. "Why are you crying?"

2. "Tell me how you are feeling right now."

3. "Let's wait for the results before crying about them."

4. "I'm sure that you will be fine. They know right away if it's cancer."

2. Tell how you are feeling

The nurse performs discharge teaching for a client receiving warfarin. The nurse determines further teaching is required if the client makes which statement?

1. "I should increase my intake of leafy green vegetables."

2. "I will wear a Medic-Alert bracelet."

3. "I will tell the health care provider if I have black tarry stools."

4. "I need to talk with the health care provider before taking any medication."

1. I increase leafy greens

The day shift nurse reads the night shift nurse's notes entry from 0600, before providing care for the client. Which 4 findings from the night shift nurse's report most concern the day shift nurse?

1. Client in supine position.

2. Receiving oxygen at 2 L/min per nasal cannula.

3. Pulse oximeter reading 94%.

4. NG tube secured to bed frame.

5. Pulse of 90.

6. Crackles in the lungs.

7 Urinary catheter collection bag secured to bed

8. Temp of 101.2F

1,4,6,8

1. Lying supine

2. Respirations 22

3. Crackles in both fields

4. Temp 101.2

1.Aspiration

2.Aspiration, Angina, Asthma

3. Aspiration, Asthma

4. Aspiration

The client is at high risk for developing due to and the presence of . NOTE: A selection must be made for each dropdown. Aspiration pneumonia lying in a supine position a nasogastric feeding tube

1.Raise the head of the client's bed to 45 degrees.

2.Notify the physician of the client's status.

3.Stop the feeding.

4. Teach client how to use an incentive spirometer.

5. Measure the urine in the bag.

Priority or not?

1. Priority

2. Priority

3. Priority

4. Not

5. Not

The nurse ensures the client's HOB is 45 degrees. It is a priority for the nurse to complete a respiratory assessment. At this time, it is important for the nurse to ensure the x-ray is obtained to verify correct tube placement. The nurse will also administer the acetaminophen medication.

An adolescent client hospitalized for a leg fracture is reluctant to participate in physical therapy stating, "I'd rather just rest in bed and play video games." Which consequence of immobility does the nurse include when providing education to this client?

1. Delusions. 2. Diabetes mellitus. 3. Diplopia. 4. Deep vein thrombosis.

4. Deep vein thrombosis

The nurse provides care for an older adult client with a diagnosis of advanced dementia who is mostly bed confined and develops a reddened area on the right hip. Which intervention is most appropriate for the nurse to implement?

1. Encourage the client to lie on the left side.

2. Use a draw sheet to turn the client every two hours.

3. Rub lotion on the reddened area four times per day.

4. Assess bony prominences once per shift.

2. Draw sheet q 2hrs

A client reports "coughing up bloody mucus" in the mornings. The nurse tries to determine the source of the bleeding. Which action does the nurse take first?

1. Sends a specimen to the laboratory for analysis.

2. Inspects oral cavity with a pen light.

3. Elicit the gag reflex using a tongue depressor.

4. Listens to the client's lungs and breathing.

2. Inspect oral with pen light

After administering pain medication to a client, it is most important for the nurse to take which action?

1. Do not disturb the client.

2. Keep the environment cool and quiet.

3. Provide diversionary activities at short intervals.

4. Determine whether the medication is effective

4. Determine med effective or not

The nurse provides care for a client diagnosed with chickenpox. Which precaution does the nurse include in this client's plan of care? (Select all that apply.)

1. Apply a mask before entering the client's room.

2. Apply goggles before entering the client's room.

3. Assign to a private room with negative air pressure.

4. Keep the door to the client's room closed at all times.

5. Apply a mask to the client before transporting out of the room.

1,3,4,5

A client recovering from spinal surgery requests to be moved in bed. Which action does the nurse take when repositioning this client? (Select all that apply.)

1. Turn the client as one unit.

2. Raise the bed to a working height.

3. Ask one nurse to stand at the head of the bed.

4. Have the client keep the arms and hands on the bed.

5. Place two nurses on the side opposite the direction being turned.

1,2,3,5