Fundementals Exam 3 Review

An Adult with diabetes receives 20 units of insulin each morning and evening. How would the nurse teach the client how to administer their insulin?

A. Use an insulin syringe and give 20 units

B. Use a 1ml syringe and give 0.4ml

C. Use an insulin syringe and give 2ml

D. Use a tubercular syringe and give 20 units

A. Use an insulin syringe and give 20 units

A nurse is caring for a client with sustained blood loss. Which of the following is a manifestation of hypovolemia?

A. Decreased Heart Rate

B. Shortness of breath

C. Decreased Blood pressure

D. Decreased Pulse

D. Decreased Pulse

( hypovolemia= weak thready pulse )

A nurse is performing a cardiac assessment. Identify where the nurse should place the stethoscope to auscultate the client's apical pulse.

The nurse should auscultate the apical pulse in the 5th intercostal space, on the left side of the chest, over the apex of the heart

A nurse has received a change in shift report of a group of clients and is preparing her assignment. Which of the following clients should the nurse first access?

A. A client who has had a blood glucose reading at 0650 of 70

B. A client who was admitted for chest pain is reporting a new onset of indigestion

C. A client who has pneumonia and is being treated for a temp of 8.9 C (102 F)

D. A client who has been pulled out of her peripheral IV catheter and is scheduled to receive a dose of pepsin

B. A client who was admitted for chest pain is reporting a new onset of indigestion

(is unstable therefore highest priority)

A nurse in the emergency department is caring for a client who has collapsed after playing football on a hot day. After reviewing the admission laboratory findings, the nurse recognizes that these are consistent with which of the following conditions. Laboratory results: Sodium 152,

glucose 102., Potassium 3.6, Bun 18, Chloride 105, Creatine 0.7

A. Renal Failure

B. Low protein diet

C. Dehydration

D. Syndrome of inappropriate antidiuretic hormone

C. Dehydration

(Hypernatremic= high sodium)

A nurse is reviewing a client's lab results. Which of the following lab values should the nurse report to the provider?

A. A sodium of 126

B. A potassium of 3.6

C. A magnesium of 1.9

D. A chloride of 99

A. A sodium of 126

(Hyponatremic=low sodium, adrenal insufficiency)

The nurse is preparing to administer jejunction 1mg PO to a client; the amount of decoction available is 0.5mg per tab. How many tabs should the nurse administer? (Round your answer to the nearest whole number)

2 Tablets

A nurse is reviewing the admitting prescription for a client; the nurse notes that one medication is 3 times the usual amount of the medication. Which of the following actions should the nurse take?

A. Contact the pharmacy and confirm the dosage is safe to administer

B. Ask another nurse to verify if the dosage is appropriate for the client

C. Contact the provider to question the dosage

D. Inform the charge nurse and administer the dose of the medication

C. Contact the provider to question the dosage

A nurse is having trouble reading the provider's writing on a prescription for a client's medication. Which of the following actions should the nurse take?

A. Clarify the type of medication with the family

B. Review the medication on the admission record

C. Send the prescription to the pharmacy to clarify

D. Contact the provider to clarify the prescription

D. Contact the provider to clarify the prescription

A home care nurse is educating a client with diabetes on how to self-administer insulin. Which teaching point should the nurse include in the education plan?

A. Each time you give the injection, rotate the injection site

B. Store insulin needles and syringes in a glass container between use

C. Syringes and needles may be reused up to 3 times

D. For each injection, use the same site on the body

A. Each time you give the injection, rotate the injection site

A nurse is drawing out opioid pain medication into a syringe, preparing to administer the medication. The client refuses to state that the pain is currently controlled at a level 2 on a pain scale of 1-10. Which action should the nurse take to waste the medication?

A. Waste the medication with 2 nurses present

B. Waste the medication with another nurse witness present

C. Hold the medication in the cargo pocket to give later

D. Squirt the medication down the patient's sink while the patient watches

B. Waste the medication with another nurse witness present

(another nurse must be present and sign of on the wasted medication)

The nurse is caring for a client who is dying. The nurse overhears the client saying, "God, if you will only let me live to see my daughter get married, I promise I will start going to church again." The nurse understands that the client is in which stage of grief, according to Kubler Ross:

A. Bargaining

B. Denial

C. Depression

D. Acceptance

A. Bargaining

The Nurse is working with a client whose wife died 4 years ago. Which assessment finding might prompt the nurse to prioritize assessment for dysfunctional grief?

A. Leaving his wife's clothes and belongings intact

B. Displaying multiple photographs of his wife

C. Talking humorously about his wife's absent mindingingness

D. Explaining to the nurse in ways which his life has changed

A. Leaving his wife's clothes and belongings intact

A nurse is caring for a client who is dying of cancer; his family members have expressed profound sorrow over their forthcoming loss. Which nursing diagnosis will the nurse provide for the family;

A. Anticipatory grieving related to the loss of a family member as evidenced by sorrow

B. Dysunfcutinal grieving related to the loss of a family member as manifested by behaviors

C. Potential for grief related to loss of family members and sorrow

D. Dysfunction grief relating to the future loss of a family member manifested by family developmental regression

A. Anticipatory grieving related to the loss of a family member as evidenced by sorrow

A nurse administers the wrong medication to a client. Which of the following actions should the nurse take first?

A. Check the client's vital signs

B. Notify the Provider

C. File an incident report

D. Document the client's position and document in EMAR

A. Check the client's vital signs

A nurse is teaching a class about converting household measurements into the metric system. Which of the following information should the nurse include?

A. 1 tsp = 10ml

B. 1 cup = 240ml

C. 2 tbs= 15ml

D. 1 pint = 960 ml

B. 1 cup = 240ml

A nurse is caring for a client, desiring their wound care to be provided at 1400, and the nurse returns at 1400 for wound care for the client. Which of the following ethical principles is the nurse demonstrating:

A. Fidelity

B. Automny

C. Justice

D. Viracity

A. Fidelity

(Fidelity= ethical principle that provides trust within a nurse-patient relationship)

When administering a subcutaneous injection to a client, the needle pulls out of the skin when the skin fold is released. What would be the appropriate next action of the nurse in this situation?

A .Engage the safety shield on the needle guard and discard the needle appropriately

B. Pull out and discard the needle.

C. Document the incident and inform the primary care provider.

D. Discard the equipment and start the procedure from the beginning.

A. Engage the safety shield on the needle guard and discard the needle appropriately

The nurse is preparing to administer an IM injection into a client using the Z track method. Which procedure should the nurse use to administer the infection?

A. Pull skin in subacute tissue to 1.1 to 1.5 inches on one side of the injection site while injecting

B. Insert the needles until the entire bubble lies immediately under the skin while injecting

C. Pull the skin top between two fingers while injecting

D. Pinch the skin up between two fingers while injecting

A. Pull skin in subacute tissue to 1.1 to 1.5 inches on one side of the injection site while injecting

The nurse is preparing to give 2ml of an antibiotic injection through the Instramucsular route. The nurse knows to use a 3ml syringe with what type of needle? (what gauge)

A. 22

B. 16

C. 25

D. 29

A. 22

(For IM injections, the needle size should be 20-22 gauge needle)

A hospice nurse is caring for a group of clients with terminal illnesses. Which is the highest care priority for the client in the dying process?

A. Pain management

B.Skin care

C. Hydration

D. Hygiene

A. Pain management

The nurse is assessing a client's fluid balance status. Which information would the nurse document about the client's hydration?

A. Urinary output

B. Skin Color

C. Bowel sounds

D. Lung Sounds

A. Urinary output

(Urinary output= fluid balance status)

A nurse measures the client's 24-hour fluid intake and documents the findings as an accurate indicator of fluid status; what must the nurse do with the information?

A. Calculate the total intake and compare it to the total output of fluid for 24 hours

B. Compare the client's intake to a normal range of adults' fluid intake

C. Report the exact ml intake to the healthcare provider's office nurse

D. Ensure that the information is included in the verbal end-of-shift report

A. Calculate the total intake and compare it to the total output of fluid for 24 hours

A nurse is providing teaching to a client about ways to improve their health. Which of the following modifiable risk factors should the nurse include? (Select all that apply 3)

A. Alcohol consumption

B. Family history

C. Diet

D. Sedentary lifestyle

E. Weight

A. Alcohol consumption

C. Diet

D. Sedentary lifestyle

E. Weight

A nurse is planning to use the nursing process to care for a client experiencing grief. Which of the following actions should the nurse take first:

A. Incorporate the treatment into the client's care

B. Determine whether coping strategies were successful

C.Establish whether the client's grieving is healthy or complicated

D. Teach the client the stages of grief

C.Establish whether the client's grieving is healthy or complicated

When the nurse reviews the client's lab reports, it reveals sodium is 120, potassium 4.1, Calcium 9.2, and Magnesium 1.9. The nurse should notify the health care provider of the abnormal values.

A. Sodium 120

B. Potassium 4.1

C. Calcium 9.2

D. Magnesium 1.9

A. Sodium 120

(low sodium)

A nurse is assisting with caring for a client scheduled for elective surgery. The client informs the nurse that they no longer wish to proceed with surgery. Which of the following ethical principles should the nurse uphold for the client?

A. Justice

B. Fidelity

C. Autonomy

D. Veracity

C. Autonomy

A nurse is teaching about intentional torts with a group of newly licensed nurses. The nurse should include which of the following:

A. A nurse administers a client scheduled antibiotic 2 hours late because of an oversight

B. A nurse Informs their sibling who works on another unit that the nurse's client has HIV.

C. A nurse forgets to lock the heels on a bed, and the client falls.

D. A nurse witnessed the consent for surgery for a patient who received the procedure on the wrong location.

B. A nurse Informs their sibling who works on another unit that the nurse's client has HIV.

A nurse is teaching a newly licensed nurse about informed consent. Which of the following should included as the nurse's responsibility in this process?

A. Discuss the risk of the procedure with a client

B. Explain alternatives to the procedure to the client

C. Confirm the client is competent to sign for the procedure

D. Inform the client what will occur during the procedure

C. Confirm the client is competent to sign for the procedure

The nurse teaching values to a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding?

A. "A nurse's values should not be considered when making ethical decisions"

B. "A nurse's behaviors and actions are called values"

C. "It is important that the nurse is aware of the client's values"

D. "Value clarification involves maintaining clinical competency."

C. "It is important that the nurse is aware of the client's values"

A 24-year-old client in good health has begun an exercise program. The nurse should recommend what regimen?

A. A moderate-intensity aerobic exercise lasting 30 minutes a day 5 times per week

B. Mild intensity aerobic exercise lasting 45 minutes 3 days per week

C. Modertly intensive aerobic exercise lasting 1 hour 4 times per week

D. High-intensity aerobic exercise lasting 30 minutes at least 5 times per week

A. A moderate-intensity aerobic exercise lasting 30 minutes a day 5 times per week

A nurse is providing discharge instructions to a client with chronic appendicitis. Which statement by the nurse indicates the need for additional teaching related to Hypermagnesia?

A. I should not experience my urinary output due to high magnesium

B. should not experience severe muscle weakness from too much magnesium

C. I can take over-the-counter antacids for indigestion

D. I should avoid eating green vegetables, chocolates, and nuts

C. I can take over-the-counter antacids for indigestion

(High magnesium typically only occurs with increased intake of magnesium with a client with renal disease; neigh lox is a common anti acid OTC drug that increases magnesium levels)

Helping a person through grief where the nurse knows that most client wants to be left alone during grief, and the nurse should support their desire:

A. The grief steps may occur in order

B. The grieving steps may not occur in order or reoccur

C. Neglect the patient's wishes

D. Grieving has to be the same in all patients

B. The grieving steps may not occur in order or reoccur

A nurse is caring for a client diagnosed with a terminal illness. The client and the family are expressing concern about the emotional impact of the impending loss; the nurse is educating the family about anticipatory grieving. Which situation best exemplifies anticipatory grieving?

A. A family that refuses to acknowledge the seriousness of the client's illness until after the death occurs

B. A spouse who experiences intense grief after their loved one has passed away

C. Parents who begin to emotionally prepare for the loss of their child diagnosed with a life-ending illness

D. Siblings who remains emotionally distant from their dying brother until their final moments

C. Parents who begin to emotionally prepare for the loss of their child diagnosed with a life-ending illness

A nursing student is reviewing phases of post-operative care. Which statement of the student demonstrates an understanding of pre-operative nursing?

A. A pre-operative care focuses on managing pain and preventing complications after surgery

B. During the pre-operative phase, a surgical procedure is performed, and anesthesia is administered

C. Pre-operative nursing involves preparing the patient physically and emotionally for surgery

D. Pre-operative care requires close monitoring of the patient's vital signs in the pre-anesthesia holding area

C. Pre-operative nursing involves preparing the patient physically and emotionally for surgery

A nurse is conducting a post-operative assessment on a client who underwent abdominal surgery. The client returned to the surgical unit after spending time in the PACU. What is the nurse's priority assessment during the initial post-operative period?

A. Pain level and effectiveness of pain management

B. Surgical sights dressing and signs of infections

C. Respiratory status and oxygen saturation

D. Food balance and urinary output

C. Respiratory status and oxygen saturation

(always airway management, ABC)

During the post-operative time-out procedure, the surgical team discovered a discrepancy between the patient identification band and the information on the consent form. What can the pre-operative nurse do in this situation?

A. Proceed with the surgery as planned since the patient is already prepared

B. Document the discrepancy in the patient's chart and tell the surgeon after the surgery

C. Contact the surgeon immediately to discuss the identification mismatch

D. Inform the patient about the discrepancy and ask for patient verbal authorization

C. Contact the surgeon immediately to discuss the identification mismatch

A nurse is planning to administer an IM injection into a client's deltoid muscle. Which of the following actions should the nurse take?

A.Inject the medication at a 90-degree angle

B. Inject a volume greater than 2ml

C. Inject the medication 12.7 cm below the patient's acromion process

D. Use a 21 gauge needle for the injection

A.Inject the medication at a 90-degree angle

A nurse is preparing to administer a subcutaneous injection to a patient. What is the recommended degree angle to insert the needle for a subcuternous injection?

A. 90 degrees

B. 45 degrees

C.48 degrees

D. 75 degrees

B. 45 degrees

A nurse is conducting a stroke screening on a middle-aged adult during a community fair. Which assessment should raise the nurse's concern of a potential stroke risk?

A. BP: 120/80

B. Symmetry and facial features and strength

C. Inability to look at both arms equally

D. Clear and proper speech

C. Inability to look at both arms equally

A nurse is caring for a client with a history of cardiovascular disease during the assessment. The nurse notes weak peripheral pulses, delayed capillary refill, and cold, pale skin. The client reports intermitted claudation. Based on these findings, what nursing diagnosis is most important for this client

A. impaired skin integrity

B. Risk for infection

C. contemporary intolerance

D. Ineffective tissue perfusion

D. Ineffective tissue perfusion

Which client should the nurse assess for edema?

A. Client with newly diagnosed heart failure

B. Client with type 1 diabetes

C. Client who's receiving care for leukemia

D. Client with dehydration receiving IV

A. Client with newly diagnosed heart failure

(edema always goes with heart failure)

A nurse is caring for a patient diagnosed with activity intolerance related to a recent cardiac event. What is the most appropriate nursing intervention to address the patient's activity intolerance?

A. Encourage the patient to participate in vigorous aerobic exercises

B. Implement a structure of exercises program that requires minimal breaks

C. Provide rest between activities and encourage gradual activity progression

D. Advice the patient to push through fatigue to build endurance

C. Provide rest between activities and encourage gradual activity progression

The nurse provides healthy heart education to an older adult client. Which practice would the nurse recommend?

A. Exercise to lower triglycerides and raise high-density lipoprotein proteins levels (HDL)

B. Implementation of 20-minute periods after meals

C. Diet high in pottasoium

D. High protein diet to increase low-density lipoprotein levels (LDL)

A. Exercise to lower triglycerides and raise high-density lipoprotein proteins levels (HDL)

A nurse is preparing to administer 1mg of vitamin K. The nurse's medication is available in 1mg 0.5 ml. How much shoud the nurse administer? (round to the nearest tenth)

0.5ml

The nurse is teaching a client about the prevention of deep vein thrombosis (DVT). Which of the following statements by the client indicates an understanding?

A. I will keep my leg elevated as much as possible

B. I will sit for long periods without moving my legs

C. I will avoid wearing compression stockings

D. I will avoid drinking plenty of fluids

A. I will keep my leg elevated as much as possible

A healthy adult client is given an opioid prior to a surgical procedure. The nursing is completing the chart and notices the consent form was not signed by the client. Which of the following should the nurse do?

A. Notify the healthcare provider of the oversight

B. Immediately have the client sign the form

C. Make the client's family member sign the form

D. Ask the client if they still want to continue with the procedure

A. Notify the healthcare provider of the oversight