Exam 4: Fundamentals

The nurse is caring for a client on droplet precautions who has a prescription for a CT scan.  When transporting the client to radiology, the nurse should ensure that the transporter uses protective equipment correctly to reduce the environmental spread of infection when the client is outside the room.  Which instruction should the nurse give the transporter?

A nurse is caring for a homeless client who is moderately malnourished and suffering from pneumonia.  The client needs a peripheral IV line for fluid administration.  Which IV site should the nurse select to reduce the risk for infection?

The nurse is drawing blood from a client's peripheral vein for laboratory specimens.  Which of the following are correct nursing actions?  Select all that apply.

A nurse is performing a dressing change for a hospitalized client with an infected surgical incision.  Which actions should the nurse take?

The nurse plans to start an IV line on a female client hospitalized with pneumonia.  The nurse reviews the electronic medical record for relevant information and learns that the client is right-handed and has a history of a left-sided mastectomy with lymph node removal.  Which site is best for the nurse to select for the client's IV line?

The home health nurse visits a client who is rehabilitating after a tibial fracture.  Which interventions are appropriate to include in the client's teaching plan to promote safety in the home when using crutches?  Select all that apply.

A client is scheduled for an elective laparoscopic prostatectomy in the morning.  The nurse should notify the health care provider (HCP) about which assessment data as soon as possible before surgery?

A blood transfusion is prescribed for a client experiencing complications of sickle cell anemia with a hemoglobin level of 6 g/dL (60 g/L).  Which of the following actions by the registered nurse are appropriate?  Select all that apply.

A client is scheduled for coronary artery bypass surgery in the morning.  In the middle of the night, the nurse finds the client wide awake.  The client demonstrates symptoms of extreme anxiety and tells the nurse about wanting to refuse the surgery.  Which statement by the nurse would be most appropriate?

The nurse prepares to administer medications to a client.  Which of the following client data are acceptable for use as client identifiers?  Select all that apply.

A nurse administers an intramuscular (IM) injection using the Z-track technique.  Place the steps in chronological order.  All options must be used.

A client is brought to the emergency department with multiple trauma injuries.  The nurse sees the client's Jehovah's Witness identification card.  As part of providing culturally competent care, the nurse would anticipate the client accepting which of the following?  Select all that apply.

The nurse observes a student nurse administer ear drops to an elderly client to help loosen cerumen.  The nurse intervenes when the student performs which action?

In which position would the nurse place a client recovering from a right modified radical mastectomy who is admitted from the post-anesthesia unit?

The client screams at the nurse, "You are all incompetent here!  I have been waiting for 2 hours!"  How should the nurse respond initially?

The nurse precepts a nursing student caring for a client with glaucoma and observes the student administer timolol maleate, an ophthalmic medication.  Which student action indicates that further instruction is needed?

The nurse is preparing to administer an IM immunization to a 6-month-old infant.  Which needle length and injection site would be the most appropriate to minimize a local reaction to the vaccine components?

The nurse is preparing a client for a magnetic resonance cholangiopancreatography.  Which statements by the client would require the nurse to obtain further assessment data?  Select all that apply.

A client calls the nurse to report exacerbation of chronic lower back pain after working in the yard all weekend.  Knowing that this worsened back pain is probably due to acute inflammation, the nurse recommends which nonpharmacologic intervention?

The nurse teaches safety precautions of home oxygen use to a client with emphysema being discharged with a nasal cannula and portable oxygen tank.  Which client statement indicates the need for further teaching?  Select all that apply.