Exam 4: Fundamentals

The caregiver of a toddler calls the clinic because the child has accidentally ingested one capsule of amitriptyline found in the medicine cabinet.  The caregiver states that the child appears to be acting normally.  Which response by the nurse is appropriate?

The charge nurse is instructing a new graduate nurse on performing postmortem care.  Which client situations might cause the nurse to delay or not perform postmortem care?  Select all that apply.

A student nurse prepares to change a large wet-to-damp sterile wound dressing and uses a disposable moisture-proof sterile drape to set up the sterile field.  The precepting nurse intervenes when the student performs which action?

A client is receiving IV potassium.  The IV pump displays an occlusion alarm.  The tubing is free of occlusions, and the IV flushes easily without symptoms of infiltration.  Which action should the nurse take next?

A client with right-sided weakness becomes dizzy, loses balance, and begins to fall while the nurse is assisting with ambulation.  Which nursing actions would best prevent injury to the client and nurse while guiding the client to a horizontal position on the floor?

The nurse notes muffled heart tones in a client with a pericardial effusion.  How would the nurse assess for a pulsus paradoxus?

The nurse is caring for a client with active pulmonary tuberculosis.  Which elements of infectious disease precautions are mandatory for the nurse when providing routine care?  Select all that apply.

A client started a 24-hour urine collection test at 6:00 AM.  The unlicensed assistive personnel (UAP) reports discarding a urine specimen of 250 mL at 10:00 AM by mistake but adding all specimens to the collection container before and after that time.  What action should the nurse take?

The nurse is educating a client recently diagnosed with anaphylactic allergy to latex.  Which statement made by the client indicates that the client understood the condition correctly?

The nurse is assisting with procedural moderate sedation (conscious sedation) at a client's bedside.  The unlicensed assistive personnel (UAP) comes to the door and indicates that the client in the next room needs the nurse right now.  How should the nurse respond?

A client newly returned to the unit after knee surgery asks the nurse for assistance to a chair.  What action should the nurse implement first?

The client has a dislocated shoulder and the nurse is assisting the health care provider with bedside procedural moderate sedation (conscious sedation).  During the procedure, the client becomes restless and cries out "Help me!"  What action should the nurse take first?

The nurse is caring for a group of clients.  Which finding requires immediate action by the nurse?

A 3-month-old infant is treated in the emergency department for a spiral femur fracture.  The parent reports that the infant sustained the injury after rolling off the bed.  What is the priority nursing action?

The nurse is reviewing a client's preoperative questionnaire, which indicates a religious preference with spiritual needs concerning surgery scheduled later today.  Which action is most appropriate at this time?

The nurse working in an extended care facility transcribes a prescription from the health care provider for a single daily dose of 150 mg of ranitidine; this is to be taken orally at bedtime for treatment of gastroesophageal reflux disease.  Of the following prescriptions, which one is transcribed correctly?

The nurse admits an 81-year-old client with gastroenteritis.  Admission vital signs are temperature 101 F (38.3 C), blood pressure 90/42 mm Hg, pulse 118/min, and respirations 32/min.  Pulse oximetry shows 88%.  The nurse suspects which of the following factors may be affecting accuracy of the pulse oximetry reading?

The pediatric nurse is preparing to administer an acetaminophen suppository to an 11-month-old with pyrexia.  Which actions are appropriate?  Select all that apply.

Which situations would require the nurse to obtain a prescription for physical restraints?  Select all that apply.

A client with terminal cancer is prescribed fentanyl patches for pain management while receiving hospice care at home.  Which instructions related to this medication should the nurse provide?  Select all that apply.