Fundamentals of Nursing Final

A nurse is assigning tasks to an assistive personnel. Which of the following is one of the five rights of delegation?

Right supervision

RATIONALE- right task, circumstance, person, direction/communication, supervision/evaluation

A unit based council is working to improve team communication. Which issue is most likely to hinder inter professional collaboration?

Misunderstanding of each disciplines responsibilities

RATIONALE- when unclear about one another's roles, communication and collaboration break down

A charge nurse teaches staff about advantages of electronic health records. Which statement shows understanding?

They help reduce repeated diagnostic testing

RATIONALE- provide shared, real time info

A nurse is charting using the SOAP format. Which entry belongs in the 5(subjective) section?

Client states "my chest feels tight when I walk"

RATIONALE- subjective data are the clients feelings or statements

A nurse wants to review a clients previous admission for comparison. According to HIPAA, which situation allows access?

The nurse is assigned to care for client today

RATIONALE-only staff directly involved in clients care may access the record

What documentation entry should the nurse revise?

Client appears upset about upcoming surgery

RATIONALE- 'appears upset' is vague and opinion based

A client post stroke has weakness on the left side and needs help improving mobility. Which referral should the nurse anticipate?

Physical therapist

RATIONALE- focuses on strength, mobility, gait, balance

A client will need wound care at home after discharge. Which team member should the nurse contact to help arrange these services?

Social worker

RATIONALE- social workers coordinate community resources, including home health services

On admission, the nurse reviews a list of medications sent from the clients nursing home. This step is part of medication reconciliation because it:

Confirms what the client was taking at the previous facility

RATIONALE- med reconciliation compares all sources to create an accurate, complete list

A client with schizophrenia is being discharged and is currently unhoused. Which team member is best suited to help secure safe housing?

Social worker

RATIONALE- assist with housing, financial resources, community programs

A client on an inpatient mental health unit is learning job readiness and basic work skills before discharge. To which team member should the nurse expect a referral?

Occupational therapist

RATIONALE- help client regain skill for work/daily functioning

Which situation best illustrates inter professional collaboration for a client with complex needs?

The nurse consulting a dietitian about enteral feeding

RATIONALE- collaboration occurs when professionals from different disciplines

Which statement by a nurse reflects a barrier to effective inter professional collaboration?

We rarely communicate directly with the respiratory therapist

RATIONALE- lack of communication leads to fragmented care

A client has a new tracheostomy and will require help managing secretions and ventilatory needs. The nurse anticipates a referral to:

Respiratory therapist

RATIONALE- specialize in airway management

Which item is typically included in clients EHR?

Clients demographic and insurance information

RATIONALE- EHR contains health related and identifying data

A preceptor asks a new nurse about the primary purpose of documentation in the health record. Which response is most accurate?

It lets each team member record the care they provided

RATIONALE- documentation is formal communication tool to record

A prescription reads: "give metoclopramide 10 mg PO ac" the nurse interprets "ac" to mean:

Before meals

A nurse teaches copping and stress management techniques to clients attending cardiac rehabilitation group after myocardial infarction. This is which level of prevention?

Tertiary

RATIONALE-helps clients adapt to and manage established disease

On a busy surgical unit, which non pharmacologic intervention best promotes sleep at night?

Reducing noose and clustering nighttime care

RATIONALE- minimizing environmental stimuli improves sleep quality

Which statement by an older adult best indicates correct understanding of health promotion?

I still see my dentist regularly even with partials

RATIONALE- preventative measures for older adults

A confused older adult with dementia is admitted after hip surgery. Which action is most appropriate?

Provide a consistent routine and familiar structure

RATIONALE-clients with dementia function best with predictable routines

The nurse teaches health risks to a group of young adults. Which statement shows correct understanding?

Managing my stress level can lower my chance of getting sick

RATIONALE-chronic stress contributes to many illnesses

Which condition most directly increases an older adults risk for falls?

Uneven weight bearing and limited joint motion

RATIONALE-impaired mobility and balance directly compromise stability

On admission, the nurse notes a shallow open ulcer with a pink-red wound bed and no slough on the clients sacrum. How should this pressure injury be staged?

Stage 2

RATIONALE-partial thickness skin loss with exposed dermis

What is the first nursing action in preventing pressure injuries?

Assess the clients individual risk factors

RATIONALE- assessment must precede interventions

Wile cleansing a surgical incision, which technique should the nurse use?

Cleanse from incision outward toward the surrounding skin

RATIONALE- always move from least contaminate to most contaminated

Why should a nurse administer an analgesic 30 minutes before a painful dressing change?

to improve the clients comforts and cooperation

RATIONALE- premedication minimizes pain, reduces anxiety, and promotes participation in care

A stroke patient has decreased mobility, placing them at risk for skin breakdown. What initial action should the nurse take?

Use mild cleansers and gently dry the skin after bathing

RATIONALE- gentle cleansing and thorough drying are first line measures

Which finding indicates the greatest risk for pressure injury development?

Fecal incontinence

RATIONALE- moisture and stool enzymes macerate skin and increase breakdown

Which measure provides the most reliable indication of a patients pain relief?

Patient reports their pain is now 2/10

RATIONALE- physiologic and behavioral cues are indirect

A post pop orthopedic client reports "much worse pain than anyone else on the unit". What is the nurses best initial action?

Ask the client to rate the pain and describe its characteristics

RATIONALE- pain is subjective

A hypothermic client has a pulse oximeter on the finger, but the reading is erratic and low quality. What should the nurse do first?

Assess the perfusion to the fingers and choose a better site

RATIONALE-hypothermia can cause poor peripheral circulation

Which statement by the nurse best reflects therapeutic communication about pain?

Let's talk about what's worked for you before and decide together

RATIONALE-validates patients experience and promotes collaboration

To reduce modifiable factors that can intensify pain on which areas should the nurse focus?

anxiety, fear

RATIONALE- reduced with education

Which statement by a nurse caring for a client with chronic pain shows understanding of reassessment?

Ill reassess pain about an hour after giving oral analgesic

RATIONALE- oral meds should be reassessed 1 hour after dosing

Before examining the external genitalia of a 25 year old women of Chinese heritage, what is the nurses primary action?

ask how she feels about the exam and explain the procedure

RATIONALE- some cultural groups may view genital exams as shameful or offensive

Before taking a clients blood pressure, which fact is most important for the nurse to recognize?

Smoking causes vasoconstriction, temporarily increasing BP

RATIONALE- nicotine-vasoconstriction- transient BP

At a community screening, the nurse knows which group has the highest overall incidence of hypertension?

African American

A trauma client has a fractured jaw and missing teeth, with cool, clammy skin. Which route should be used to obtain the most appropriate temperature?

tympanic

A client with a pressure injury has new lab results. Which elevated value most strongly suggests infection?

white blood cell count

RATIONALE- elevated WBC indicate immune response to infection

While ambulating, a weak patient starts to lose balance. What is the nurses safest immediate action?

support and lower the patient slowly to the floor

In a client with a long term indwelling foley catheter, the nurse should be most alert for which complication?

urinary tract infection

Which finding best indicates that a post op clients bowel function is returning and oral intake may soon resume?

bowel sounds present in all quadrants and passing flatus

For a client with a new ileostomy, which nursing diagnosis has the highest immediate prioirty?

impaired skin integrity related to liquid effluent

RATIONALE- continuous stool can rapidly breakdown peristomal skin, risking infection and appliance failure

Which comment by the assistive personnel about a client on a full liquid diet shows need for further clarification?

i can bring oatmeal

When caring for a client with an ileostomy, which action by the nurse is most appropriate?

empty the pouch when it is 1/3-1/2 full

RATIONALE-too heavy- loosens the seal

A client with a hip fracture must use a bedpan in bed and is unable to defecate. Which nursing action is most helpful?

elevate the head of the bed while on the bedpan

RATIONALE- mimics normal sitting posture and improves ab muscles used for defecation

To promote regular bowel elimination, which meal should the nurse recommend?

chicken salad with grapes on whole wheat bread

RATIONALE- enhance stool bulk

A client reports no bowel movement for 3 days. Which assessment finding is most consistent with this history?

hypoactive bowel sounds

RATIONALE- constipation= hypoactive bowels, firm/distended abdomen

A male client is uncomfortable and has not voided for several hours, bladder palpation suggest urinary retention. Which intervention should the nurse try first?

Assist the client to stand at the bedside to void

A nurse observes an assistive personnel (AP) providing care to a client with an indwelling urinary catheter. Which AP action requires the nurse's immediate intervention?

A. Securing the catheter to the client's thigh

B. Keeping the drainage tubing free of kinks

C. Emptying the drainage bag when it is half full

D. Hanging the drainage bag on the bed side rail

D. Hanging the drainage bag on the bed side rail

Two hours after a continuous tube feeding is initiated, a client develops watery diarrhea. What is the nurse's most likely suspicion?

A. Antibiotic-associated diarrhea

B. Clostridioides difficile infection

C. Intolerance to the enteral formula

D. Poor hand hygiene during preparation

C. Intolerance to the enteral formula

.A client receives several medications through a nasogastric tube. The nurse wants to prevent the tube from clogging. Which action is best?

A. Crush all tablets and mix them into one cup of water

B. Flush the tube only after all medications are given

C. Instill undiluted, nonliquid medications

D. Request liquid formulations of medications from the pharmacy

D. Request liquid formulations of medications from the pharmacy

A client receiving a gastric tube feeding reports cramping and fullness shortly after the rate is increased. What should the nurse do first?

A. Cool the formula to provide numbing relief

B. Switch to a high-fat formula

C. Slow the feeding rate

D. Stop the feeding and notify the provider immediately

C. Slow the feeding rate

A client on total parenteral nutrition (TPN) reports intense thirst and headache and is lethargic with high urine output. Which complication does the nurse suspect?

A. Hypoglycemia

B. Hypocapnia

C. Hypercapnia

D. Hyperglycemia

D. Hyperglycemia

A client with chronic heart failure asks how to monitor fluid retention at home. Which instruction should the nurse emphasize?

A. "Check your heart rate before bed each night."

B. "Make sure your urine is bright yellow."

C. "Decrease all fluids after 6 p.m."

D. "Weigh yourself every morning before breakfast."

D. "Weigh yourself every morning before breakfast."

Which finding best indicates that a client's dehydration has been corrected?

A. Clear lung sounds

B. No jugular venous distention

C. 1,300 mL of pale yellow urine output in 24 hr

D. Verbalization of "I drank a lot today"

C. 1,300 mL of pale yellow urine output in 24 hr

The preceptor observes a new nurse suctioning a fresh tracheostomy. Which actions indicate the need for further teaching?

A. Elevating the head of the bed before suctioning

B. Applying suction only while withdrawing the catheter

C. Rotating the catheter as it is withdrawn

D. Positioning the client flat in a supine position

E. Lubricating the catheter with saline before inserting into tracheostomy

D. Positioning the client flat in a supine position

E. Lubricating the catheter with saline before inserting into tracheostomy

A client is receiving IV fluids through a peripheral line. Which task is appropriate for the nurse to delegate to the assistive personnel (AP)?

A. Adjusting the IV infusion rate

B. Starting a new IV line

C. Changing the IV site dressing

D. Documenting the client's oral and IV intake

D. Documenting the client's oral and IV intake

A client with a tracheostomy has thick secretions. Which intervention best promotes airway clearance?

A. Routine suctioning every 4 hours

B. Deflating the cuff prior to each cough

C. Instilling normal saline down the trach

D. Delivering humidified oxygen via tracheostomy collar

D. Delivering humidified oxygen via tracheostomy collar

The nurse suspects the client has increased afterload related to hypertension.

Which device is most useful to assess this?

A. Pulse oximeter

B. Nasal cannula

C. Blood pressure cuff

D. Yankauer suction catheter

C. Blood pressure cuff

Which client statement indicates a need for further teaching about healthy sleep practices?

A. "I try not to nap during the day."

B. "I go to bed and get up at the same times every day."

C. "I like a light snack and warm bath before bed."

D. "I usually fall asleep with the TV on in my room."

D. "I usually fall asleep with the TV on in my room."

A client consumed: 8 oz of milk, 6 oz of tea, & cup (4 oz) of ice cream, and received 250 mL IV fluids during an 8-hr shift. Which total intake should the nurse document?

A. 540 mL

B. 650 mL

C. 790 mL

D. 900 mL

C. 790 mL

The nurse must give 1 ml of an IM antiemetic to an average-sized adult. Which syringe and needle is most appropriate?

A. 3 mL syringe, 27-gauge, %-inch needle

B. 3 mL syringe, 25-gauge, 1-inch needle

C. 3 mL syringe, 20-gauge, 2-inch needle

D. 3 ml syringe, 22-gauge, 1%-inch needle

D. 3 ml syringe, 22-gauge, 1%-inch needle

A client will self-administer anticoagulant injections at home. How can the nurse best evaluate learning?

A. Provide written step-by-step instructions

B. Ask the client to verbalize each step

C. Call the client the next day and ask how it went

D. Observe the client correctly perform the injection

D. Observe the client correctly perform the injection

Which ordered medication will provide the most rapid pain relief for a client in severe acute pain?

A. Oral acetaminophen

B. IM ketorolac

C. Subcutaneous morphine

D. IV hydromorphone

D. IV hydromorphone

A client refuses a scheduled medication. What is the nurse's first action?

A. Hide the medication in food

B. Document the refusal and move on

C. Explain the importance of taking the medication

D. Ask the client to share why they do not want it

D. Ask the client to share why they do not want it

The nurse realizes a medication error has occurred. What is the immediate priority?

A. Complete an incident report

B. Call the pharmacy

C. Notify risk management

D. Assess the client's status and vital signs

D. Assess the client's status and vital signs

While preparing a client's medication, a tablet is accidentally dropped on the countertop. What should the nurse do first?

A. Pick up the tablet with its wrapper and reuse it

B. Place it in a clean medication cup

C. Discard the tablet and obtain a new dose

D. File an incident report

C. Discard the tablet and obtain a new dose

After caring for a client in airborne precautions, which item of PPE should the nurse remove first?

A. Gown

B. Mask/respirator

C. Goggles/face shield

D. Gloves

D. Gloves

Which statement should the nurse include for a client newly prescribed home oxygen?

A. "You can adjust the flow rate if you feel short of breath."

B. "Store your oxygen cylinders lying flat under the bed."

C. "You may use wool blankets as long as they're clean."

D. "Do not change the prescribed flow rate on your oxygen equipment."

D. "Do not change the prescribed flow rate on your oxygen equipment."

Which client should be placed in the room closest to the nurses' station?

A. Client with severe migraine requesting frequent pain medication

B. Client with suspected TB on airborne isolation

C. Client with new-onset confusion after a head injury

D. Client with atrial fibrillation on remote telemetry

C. Client with new-onset confusion after a head injury

A 70-year-old client has a yellow fall-risk armband. Which behavior shows understanding of fall-prevention teaching?

A. Removing the band for showering

B. Insisting on evening diuretics

C. Wearing nonskid red socks when out of bed

D. Cutting off the band because it is uncomfortable

C. Wearing nonskid red socks when out of bed

Medical vs. surgical asepsis for dressing change

A nurse is about to change a postoperative sterile dressing. Which action best demonstrates correct use of medical and surgical asepsis?

A. Using sterile gloves to remove the old dressing

B. Wearing clean gloves to remove the dressing and clean supplies to redress

C. Using clean gloves to remove the dressing, then sterile supplies and gloves to apply the new dressing

D. Wearing sterile gown and gloves for the entire procedure

C. Using clean gloves to remove the dressing, then sterile supplies and gloves to apply the new dressing

A client has a confirmed Clostridioides difficile infection. Which instruction is most important for the nurse to give the assistive personnel?

A. "Use an N95 mask when in the client's room."

B. "Place the client on droplet precautions."

C. "Teach the client to cover their mouth when coughing."

D. "Wash hands with soap and water after removing gloves."

D. "Wash hands with soap and water after removing gloves."

A nurse develops a plan of care for a client whose cultural background differs from the nurse's. What is the best next step?

A. Ask the charge nurse to review the care plan

B. Immediately implement the planned interventions

C. Delegate portions of the plan to assistive personnel

D. Review the plan with the client and invite feedback

D. Review the plan with the client and invite feedback

Which nursing diagnoses directly reflect a client's learning needs?

A. Deficient knowledge

B. Risk for impaired skin integrity

C. Readiness for enhanced knowledge

D. Noncompliance

E. Impaired physical mobility

A. Deficient knowledge

C. Readiness for enhanced knowledge

D. Noncompliance

A client who is deaf will receive pre-op instructions. Which strategy supports effective learning?

A. Relying on verbal explanation while speaking loudly

B. Asking a family member to interpret

C. Placing an interpreter behind the client

D. Providing written materials and visual aids

D. Providing written materials and visual aids

Before teaching about insulin administration, which factors should the nurse assess to determine the client's ability to learn?

A. Motivation and cultural background

B. Stage of grief and coping style

C. Developmental level and physical abilities

D. Family support and financial resources

C. Developmental level and physical abilities

A sedentary 72-year-old wants to "start exercising." Which activity should the nurse recommend?

A. Jogging several miles daily

B. High-impact aerobics

C. Competitive tennis

D. Daily brisk walking on level ground

D. Daily brisk walking on level ground

Two hours after giving an analgesic, the nurse asks, "How is your pain now?" This focuses on which step of the nursing process?

A. Assessment

B. Planning

C. Implementation

D. Evaluation

D. Evaluation

A client suddenly reports new chest pain. What is the nurse's initial action?

A. Notify the provider

B. Request a stat chest x-ray

C. Administer the ordered PRN pain medication

D. Reassess the client's pain and associated symptoms

D. Reassess the client's pain and associated symptoms

While assessing a casted leg, a client mentions difficulty sleeping since admission. What is the best nursing response?

A. "Let's focus on your leg right now."

B. "I'll let the next shift explore that with you."

C. "I'll document that you're not sleeping well."

D. "Tell me what your normal sleep is like and when the trouble started."

D. "Tell me what your normal sleep is like and when the trouble started."

To obtain an accurate blood pressure, which action is essential?

A. Place the cuff loosely so it can rotate on the arm

B. Use a cuff whose width is about 40% of the arm's circumference

C. Measure only in the early morning

D. Have the client hold the arm above heart level

B. Use a cuff whose width is about 40% of the arm's circumference

A partner is learning to check a client's blood pressure at home. Which action indicates the need for further teaching?

A. Aligning the cuff bladder over the brachial artery

B. Ensuring the gauge starts at zero

C. Wrapping the cuff snugly around the arm

D. Holding the client's arm above heart level while inflating

D. Holding the client's arm above heart level while inflating

A client with mild depression asks about herbal options. Which supplement is commonly used for this purpose?

A. Ginseng

B. Ginkgo biloba

C. Black cohosh

D. St. John's wort

D. St. John's wort

Which herbal supplement should the nurse recommend as possibly helpful in reducing nausea?

A. Cranberry

B. Echinacea

C. Garlic

D. Ginger

D. Ginger

An RN delegates routine vital-sign measurement to a UAP. Legally, the RN is responsible for:

A. Allowing the UAP to interpret abnormal values

B. Having no further responsibility once the task is assigned

C. Ensuring the nurse manager assumes accountability

D. Evaluating the results and acting on any abnormalities

D. Evaluating the results and acting on any abnormalities

Which task is appropriate to delegate to an experienced UAP?

A. Teaching a client to use a walker

B. Administering oral meds to a stable client

C. Assessing pain after an analgesic

D. Collecting a routine urine specimen from a stable client

D. Collecting a routine urine specimen from a stable client

A charge nurse reviews documentation principles with a new nurse. Which statement is accurate?

A. "Only the provider's notes can be used in court."

B. "You may document your interpretation of why the client is anxious."

C. "All hospital employees may read any chart as they wish."

D. "The medical record is a legal document and may be used as evidence.

D. "The medical record is a legal document and may be used as evidence.

Which action demonstrates proper documentation practice?

A. Recording care that another nurse performed

B. Using correction fluid to cover a charting error

C. Charting interventions before they are carried out

D. Documenting objective, factual observations of the client

D. Documenting objective, factual observations of the client

Prior to administering a bolus tube feeding via NG tube, which action should the nurse take first?

A. Check gastric residual

B. Flush the tube with water

C. Verify tube placement

D. Elevate the head of the bed to at least 30-45°

D. Elevate the head of the bed to at least 30-45°

The nurse elevates the head of the bed during an enteral feeding. The primary purpose is to:

A. Make the nurse's body mechanics easier

B. speed tne Tiow ortormula into the stomach

C. Prevent gastric contents from entering the airway

D. Reduce abdominal bloating

C. Prevent gastric contents from entering the airway

Which physiologic change most directly impairs oxygen transport in the blood?

A. Daily fluid intake of 1 L

B. Decreased hemoglobin concentration

C. Lack of vitamin supplements

D. Brown hair color

B. Decreased hemoglobin concentration

Which position best promotes lung expansion for a client with dyspnea?

A. Supine

B. Trendelenburg

C. Prone

D. High Fowler's (sitting upright)

D. High Fowler's (sitting upright)

Which condition most interferes with effective gas exchange in the lungs?

A. Mild dehydration

B. Hypocalcemia

C. Increased fluid in the alveoli

D. Mild hyperkalemia

C. Increased fluid in the alveoli

During a diabetes class, which client behavior best demonstrates learning in the psychomotor domain?

A. Explaining the purpose of insulin

B. Verbalizing signs of hypoglycemia

C. Expressing acceptance of diet changes

D. Correctly performing a self-insulin injection

D. Correctly performing a self-insulin injection

Which type of learning task belongs to the psychomotor domain?

A. Choosing between ethical options

B. Describing the side effects of a drug

C. Expressing relief about treatment

D. Practicing crutch walking up and down a step

D. Practicing crutch walking up and down a step

Which statement best describes the psychomotor learning domain?

A. It involves changing attitudes and values

B. It emphasizes understanding principles and theories

C. It focuses on physical performance and coordinated movement

D. It involves complex moral decision-making

C. It focuses on physical performance and coordinated movement

When delegating tasks to a UAP, what is the most important consideration?

A. Whether the nurse is very busy

B. How difficult charting the task will be

C. Whether the task will save the nurse time

D. The stability and predictability of the client's condition

D. The stability and predictability of the client's condition