Exam 4: Fundamentals

A graduate nurse (GN) is caring for a client with right lower leg cellulitis that is seeping clear fluid.  Which action by the GN requires intervention by the supervising nurse?

The nurse prepares to assist the health care provider with a lumbar puncture on a child with suspected meningitis.  Place the procedural steps in the correct order.  All options must be used.

The nurse is caring for a client with newly prescribed hearing aids.  Which of the following actions by the client indicate proper use and care of hearing aids?  Select all that apply.

The nurse is drawing a blood specimen from a client's central line.  Identify the steps necessary to prevent transmission of infection while performing this procedure.  Select all that apply.

The nurse provides an in-service for hospital staff on how to prevent pressure injuries in clients with limited mobility.  Which instructions are appropriate for the nurse to include?  Select all that apply.

The nurse prepares to care for a client being admitted with a confirmed diagnosis of Middle East respiratory syndrome.  Which personal protective equipment will the nurse use when providing care to the client?

A client has been admitted with a catheter-associated, vancomycin-resistant enterococcal bacteremia.  Which interventions should the nurse implement?  Select all that apply.

A client is seen in the clinic for the third time for a nonhealing, infected diabetic foot ulcer.  The client is able to verbalize the correct procedure for wound care but reports not adhering to the ordered routine at home.  What intervention does the nurse prioritize to promote proper self care?

The triage nurse has one isolation room left in the emergency department.  Which priority client should be assigned to this room?

A hospitalized client is scheduled for a percutaneous kidney biopsy at 10 AM.  At 8 AM, the nurse reviews the client's vital signs and most current serum laboratory results.  Which finding is most important to report to the health care provider (HCP)?

The nurse cares for a client admitted to the hospital following a motor vehicle accident caused by the client's newly diagnosed seizure disorder.  The health care provider prescribes seizure precautions for the client.  The nurse prepares to initiate which interventions?  Select all that apply.

A nurse is assisting with the care of a newborn during circumcision.  Which is an appropriate intervention?

A nurse is caring for a group of clients on a medical surgical unit.  Which client is most at risk for contracting a nosocomial infection?

It is 0700 and the nurse is caring for an 84-year-old client with dementia and a fractured hip.  The client has been disoriented to time, place, and person since admission.  The client moans frequently and grimaces when moving.  He is prescribed morphine IV every 2 hours as needed for pain and was last medicated at 0530.  He is scheduled for surgery at 1000 to repair the hip fracture, but the consent has not yet been signed.  The client's spouse and child are to arrive at 0900.  Which intervention should the nurse carry out first?

The charge nurse must assign rooms to 4 clients who are scheduled for admission.  Which client has the highest priority for a private room assignment?

The same-day surgery nurse performs the preoperative assessment for a client with a history of coronary artery disease scheduled for an elective laparoscopic cholecystectomy.  Which statement made by the client is critical to report to the health care provider (HCP) before the surgery?

The graduate nurse (GN) is reinforcing education on sitting on and standing up from a chair to a client with crutches.  Which instruction by the GN would cause the supervising nurse to intervene?

The nurse is preparing to suction secretions from the airway of an unconscious client whose lungs are mechanically ventilated with an endotracheal tube.  Place the steps for suctioning the endotracheal tube in the correct order.  All options must be used.

A client expresses concern about facial appearance after surgery for excision of a melanoma on the side of the nose.  What is the best response by the nurse?

Which measures will help prevent falls in the elderly clients of a long-term care facility?  Select all that apply.