Exam 4: Fundamentals

The nurse performs nasogastric (NG) tube insertion using a large-bore NG tube on a hospitalized client with a gastrointestinal bleed.  During insertion, after the tube passes the nasopharynx, the client begins to cough and gag.  Which action should the nurse take first?

The parent of a 3-year-old calls and tells the nurse of finding the child in the bathroom with an empty bottle of mouthwash.  The parent thinks that the bottle was about one quarter full.  What is the nurse's priority response?

A 25-year-old client is about to undergo a unilateral orchiectomy for treatment of testicular cancer.  The client says to the nurse, "I'm so worried that my future spouse is going to call off our engagement."  What is the best response by the nurse?

The nurse accidentally sticks him/herself in the finger with a client's contaminated needle.  The client has HIV infection.  Place in order the steps the nurse should take.  All options must be used.

While turning a client, the nurse observes that the client's radiation implant has dislodged and is now lying on the linens.  Which action by the nurse is appropriate?

The inpatient hospice nurse is caring for a Muslim client newly admitted with terminal cancer.  Which of the following interventions would the nurse anticipate for this client?  Select all that apply.

A client is being discharged after having a coronary artery bypass grafting (CABG) x 5.  The client asks questions about the care of chest and leg incisions.  Which instructions should the registered nurse include?  Select all that apply.

The nurse is caring for a client who develops Clostridium difficile colitis after multiple days of antibiotic therapy.  Which infection control measures are appropriate to implement?  Select all that apply.

The nurse has unlicensed assistive personnel (UAP) caring for a client with an acute attack of Meniere disease.  Which action by the UAP will require follow-up by the nurse?

The nurse is caring for a hospitalized client with an acute exacerbation of heart failure.  The client receives digoxin 0.5 mg PO once daily, furosemide 40 mg PO twice daily, and potassium chloride (KCl) 20 mEq PO twice daily.  The client's child reports that the client has trouble swallowing the large KCl pill.  The client's potassium level is 3.7 mEq/L (3.7 mmol/L).  What action should the nurse take first?

The nurse prepares to insert a large-bore nasogastric tube for gastric decompression.  After obtaining equipment, the nurse identifies the client, performs hand hygiene, applies clean gloves, assesses nares, and selects a naris.  Place the remaining steps in the correct order.  All options must be used.

The nurse working in an intensive care unit cares for a client with a left triple lumen subclavian central venous catheter (CVC).  The nurse should call the primary health care provider (HCP) for clarification prior to implementation when recognizing that which prescription is an error?

A home health nurse is supervising a home health aide who is changing the dressing for a client with a chronic heel wound.  Which actions by the aide indicate adherence to appropriate infection control procedures?  Select all that apply.

Which procedures are appropriate for the nurse to use when obtaining an adult client's blood for a laboratory test?  Select all that apply.

A 55-year-old male client has a 16-Fr indwelling urethral catheter with a 5-mL balloon inserted to relieve postoperative urinary retention.  The nurse observes urine leaking from the insertion site, past the catheter.  What is the nurse's first action?

The nurse is caring for a 48-year-old executive on the cardiac unit who has just been diagnosed with primary hypertension.  Which teaching strategy implemented by the nurse is most likely to be effective for this client?

The nurse is providing first aid at an outdoor festival when a client reports dizziness and weakness.  The client is flushed, sweating, nauseated, and slightly tachycardic.  Which action is most appropriate at this time?

The occupational health nurse administers an intradermal tuberculin skin test (TST) to a health care worker (HCW).  The site must be assessed for a reaction afterward.  The nurse instructs the HCW to return in how many hours?

The clinic nurse is assessing the client's understanding of tiotropium, which has been prescribed for chronic obstructive pulmonary disease (COPD).  Which statement indicates that the client has a correct understanding of this medication?

The nurse is caring for a client who weighs 450 lb (204.1 kg) 2 days after bariatric surgery.  The client is pleasant, cooperative, and able to fully bear weight.  What would be the most appropriate method for transferring this client safely?