Exam 4: Fundamentals

The nurse is teaching a client with insomnia about techniques to improve sleep habits.  Which statement by the client requires further teaching?

The school nurse is speaking with the parent of a fourth grade student about a bed bug that was found on the child's sweater.  The parent confirms that their home is infested but that the issue is being resolved.  Which is the best action by the nurse?

The nurse is caring for an agitated client with dementia who is pulling at the oxygen and IV tubing.  Wrist restraints are applied after less-restrictive safety measures have been ineffective.  Which actions are appropriate to protect the client from injury?  Select all that apply.

A female client is admitted to the emergency department after a motor vehicle collision.  The client is unresponsive and on a mechanical ventilator.  Which actions should the nurse perform?  Select all that apply.

The charge nurse is preparing for the admission of an elderly client with delirium and agitation associated with urinary tract infection.  To promote client safety, which intervention is most important for the charge nurse to implement?

A client arrives in the emergency department on a cold winter day.  The client is calm, alert, and oriented with a respiratory rate of 20/min and a pulse oximeter reading of 78%.  The nurse suspects that the client's pulse oximeter reading is inaccurate.  Which factors could be contributing to this reading?  Select all that apply.

During a home visit, the community health nurse observes bruises in various stages of healing on the extremities and torso of an elderly client.  The client explains that the bruises are from bumping into furniture and the wall in the wheelchair.  What is the priority nursing action?

The nurse is caring for a client with partial hearing loss.  Which interventions would be appropriate to promote effective communication?  Select all that apply.

The male client had a hemicolectomy.  The client is refusing to wear the prescribed sequential compression devices (SCDs).  What is most important for the nurse to communicate to the client?

The home health nurse is following up with the parent of a Native American infant recently diagnosed with lactose intolerance.  In accordance with principles of culturally competent care, what is the most important question for the nurse to ask the parent?

The nurse is assigned to care for a hospitalized confused client with an indwelling urinary catheter.  On entering the client's room, the nurse notes the client pulling at the catheter and grimacing in pain.  Blood is trickling from the client's meatus and the urine in the drainage bag is pink.  Which action should the nurse take first?

The nurse at the radiological imaging center is admitting a client for an MRI of the right knee.  Which information obtained by the nurse should be reported immediately to the prescribing health care provider?

Which of the following drug administrations should be reported as a practice error?  Select all that apply.

A nurse in a pediatric clinic is preparing to administer ear drops to a 5-year-old.  Which is an appropriate action by the nurse?

A client with a tracheostomy is alert and oriented and able to tolerate oral intake.  Which action would be appropriate to reduce the client's risk of aspiration pneumonia?

A client is receiving normal saline 75 mL/hr and morphine sulfate via patient-controlled analgesia (PCA) bolus doses.  The PCA and normal saline tubing are connected at the "Y" site.  The nurse reviews a prescription from the health care provider to discontinue the normal saline.  What is the most appropriate nursing action?

The nurse is evaluating a return demonstration by the client of a dry dressing change.  Which action by the client would cause the nurse to intervene?

The charge nurse is planning assignments for the day.  Which clients will require the nursing staff to institute contact precautions?  Select all that apply.

The nurse is caring for an older adult client who is confused and has a high risk for falls.  The client is incontinent of urine and frequently attempts to get out of bed unassisted to use the restroom.  Which nursing interventions are appropriate when caring for this client?  Select all that apply.

The nurse is feeding a confused client via a small-bore nasoenteric tube.  The nurse observes the client pulling at the tube and then notices an increase in external tube length from the original exit mark.  After immediately stopping the feeding, which action is appropriate for the nurse to take next?