Exam 4: Fundamentals

The nurse is performing a central line tubing change when the client suddenly begins gasping for air and writhing.  Order the interventions by priority.  All options must be used.

Which interventions should the nurse perform when assisting the health care provider with removal of a client's chest tube?  Select all that apply.

A home health nurse is teaching the spouse of an elderly client who experienced a stroke ways of reducing risks for falls in the home.  Which suggestion by the spouse would be the most effective plan to prevent falls?

A client is able to partially bear weight and follow the nurse's instructions.  Which would be the most appropriate method for the nurse to use to safely transfer this client?

The nurse recognizes that which factors place a client at increased risk for falls?  Select all that apply.

The pediatric clinic nurse reinforces culturally competent care at an in-service.  Which finding would be inappropriate to include as a common dermatologic effect of alternative medicine therapies?

An unlicensed assistive personnel (UAP) is aiding a client recovering from a right-sided cerebrovascular accident with resulting mild oropharyngeal dysphagia.  The client has been placed on a dysphagia diet.  Which actions require intervention by the registered nurse?  Select all that apply.

The nurse is assessing the abdomen of a client experiencing gastrointestinal distress.  Place the answer choices in the correct order of assessment.  All options must be used.

A nurse is caring for a 3-month-old client with a new tracheostomy.  Which findings would indicate a need for suctioning?  Select all that apply.

A home health nurse visits a client with Alzheimer disease.  The caregiver appears frustrated and reports that the client has been persistently restless and agitated.  Which nursing action is the priority at this time?

While preparing to insert a peripheral IV line, the nurse notices scarring near the client's left axilla.  The client confirms a history of left breast cancer and modified radical mastectomy.  Which actions should the nurse take?  Select all that apply.

The nurse is preparing to transfer a client from the bed to the chair for the first time.  The client has generalized weakness and is unable to follow instructions.  Which would be the most appropriate method for the nurse to use to transfer this client safely?

The primary health care provider prescribes a 24-hour urine collection for a client with suspected Cushing syndrome.  Which instructions should the nurse give the client regarding this test?  Select all that apply.

The nurse cares for a child with bed bug bites.  Which parent statement indicates that further teaching is required?

Which client is at the greatest risk for development of hospital-acquired pressure injuries?

The unit implemented a quality improvement program to address client pain relief.  Which set of criteria is the best determinant that the goal has been met?

The nurse plans to start an IV line to infuse 2 units of packed red blood cells for a stable 42-year-old client with a gastrointestinal bleed.  Which IV catheter size is best?

The pediatric nurse is reinforcing education about medication administration to the parents of a 4-year-old client.  Which statements made by the parents demonstrate correct understanding?  Select all that apply.

An adult client is admitted with back pain and found to have a metastatic tumor on the spine.  The health care provider (HCP) explains that the client has few months to live and is likely to become totally paralyzed below the waist soon.  The next day, the client tells the nurse of wanting to be discharged despite the HCP's recommendation that the client stay a few more days.  Which is the most appropriate initial response by the nurse?

The nurse is contributing to the plan of care for a client who has active varicella with open, moist lesions.  Which of the following actions are appropriate to include in the plan of care?  Select all that apply.