Exam 4: Fundamentals

The nurse is providing postmortem care for a client who has died after a long hospitalization.  The client had a do-not-resuscitate prescription in place at the time of death.  Which of the following interventions should the nurse include during postmortem care in preparation for transfer to the funeral home?  Select all that apply.

A nurse is caring for 4 clients.  Which prescription by the health care provider would the nurse question and seek further clarification before administering?

Which client is most at risk for hospital-acquired methicillin-resistant Staphylococcus aureus (MRSA)?

A client who was placed in restraints appears in the hallway an hour later and states, "I'm Houdini.…  I can get out of anything.  There could be trouble now."  Which of the following is the best response to this client?

An experienced nurse precepts a graduate nurse in the intensive care unit while caring for a client with a right subclavian triple-lumen central venous catheter (CVC).  Which statement by the graduate nurse indicates understanding of the CVC?

The nurse answers a call light on a client not assigned to the nurse.  The client, who was just admitted from the emergency department, requests a cup of coffee.  What is the appropriate intervention?

The nurse dons personal protective equipment (PPE) before providing care for a client in airborne transmission-based precautions.  Place the steps for donning PPE in the appropriate sequence.  All options must be used.

The nurse observes an ambulating client begin to experience a tonic-clonic seizure.  Which nursing actions should be implemented immediately?  Select all that apply.

An adult client has developed diarrhea 24 hours after the initiation of total enteral nutrition via nasogastric tube.  The client is receiving a hypertonic formula.  What is the bestnursing action?

The nurse observes a client who is postoperative left total knee replacement use a cane.  Which action by the client indicates an understanding of the correct technique when walking down the stairs?

A nurse prepares to administer an intermittent enteral feeding via nasogastric tube to a client with a prescription for gastric residual checks before each feeding.  The nurse obtains a gastric residual volume of 80 mL.  Which action should the nurse perform next?

A postoperative client with obesity and diabetes mellitus has an abdominal incision and is at risk for poor wound healing.  Which interventions should the nurse include in the plan of care to promote wound healing and prevent dehiscence?  Select all that apply.

The nurse is suctioning the artificial airway of a conscious client.  Which actions demonstrate correct technique?  Select all that apply.

The nurse is caring for a client with a feeding tube that has become obstructed.  Which intervention should the nurse implement first to unclog the tube?

The nurse is reconstituting methylprednisolone sodium succinate for IM injection.  Place in order the steps that the nurse should perform to appropriately prepare the medication.  All options must be used.

The nurse is precepting a new graduate nurse (GN) who is administering a prefilled enoxaparin injection to an obese client.  Which action by the GN indicates the need for further education from the nurse preceptor?

The nurse in the oral surgery clinic reviews a client's medical record prior to surgery.  Which will the nurse immediately report to the oral surgeon?  Select all that apply.

The nurse is administering a pink pill to a hospitalized medical-surgical client.  The alert, oriented client says, "This is a pill I haven't seen before."  What follow-up action should the nurse take next?

The educator on a rehabilitation unit is teaching a graduate nurse (GN) about caring for clients who have had a stroke.  Which of the following statements by the GN indicate correct understanding of the teaching?  Select all that apply.

A nurse is preparing to administer 2 continuous IV medications concurrently via a 20-gauge IV.  What is the nurse's priority action?