Exam 4: Fundamentals

The nurse observes a student nurse administer a tuberculin skin test using the intradermal route.  The nurse intervenes when the student performs which action?

What nursing care related to peripherally inserted IV catheters can reduce the incidence of catheter-related infections?  Select all that apply.

The nurse is assessing a client's peripheral pulses.  The nurse palpates the top portion of the client's foot.  The right pulse is easily palpable, and the left pulse is diminished but still palpable.  How should the nurse document these findings?

A nurse on the telemetry unit is preparing client medications in the medication room at the nurse's station.  The nurse should perform which actions to be consistent with client safety practices related to medication administration?  Select all that apply.

A client is being seen in the clinic after receiving an external breast prosthesis after a mastectomy.  What question from the nurse best evaluates the effectiveness of the prosthesis on body image?

A client with Ebola was just admitted to the unit.  Which actions by the nurse would represent appropriate care of this client?  Select all that apply.

A client on fall precautions is found on the floor by the bed when the unlicensed assistive personnel make hourly rounds.  Place the actions the registered nurse should take in the appropriate order.  All options must be used.

A client is admitted to the hospital for chemotherapy complications.  Laboratory results show an absolute neutrophil count of 450 cells/mm³ (0.45 ×10⁹/L).  What information contained in the admission history of this client will need to be addressed during discharge education?

A client recovering at home following a left total knee replacement 7 days ago is using a cane to go up and down the stairs under the supervision of the home health nurse.  Which client action indicates a need for further instruction?

The nurse is preparing to irrigate the ears of a 67-year-old client with impacted cerumen.  Place the following steps for ear irrigation in the correct order.  All options must be used.

The nurse working in an intensive care unit receives a prescription from the primary health care provider to discontinue a triple-lumen subclavian central venous catheter.  Which interventions will help prevent air embolism on removal?  Select all that apply.

The nurse is providing discharge instructions to a 70-year-old client newly diagnosed with heart failure who has a low literacy level.  What are some teaching strategies that the nurse can use for this client?  Select all that apply.

The nurse observes a client self-administering nasal fluticasone.  Which observation would require the nurse to intervene and provide further teaching?

An unconscious client is brought to the emergency department by the paramedics after being hit by a car.  An emergency craniotomy is required.  The client has no identification.  What action should be taken next?

The nurse prepares to exit the room of a client on airborne and contact isolation precautions.  Place the following nursing actions in the correct order.  All options must be used.

A client with renal failure recently started dialysis and is unable to work due to ongoing health problems.  The client's spouse has started working for a cleaning service to replace the lost income.  The dialysis nurse notices that the client has become withdrawn and increasingly frustrated by small inconveniences when coming to dialysis.  Which is the most appropriate first response by the nurse?

A client with a nasogastric tube is prescribed intermittent bolus enteral feedings with routine gastric residual checks.  Which of the following actions by the nurse are appropriate?  Select all that apply.

There has been an explosion at a local chemical plant.  A private car arrives at the emergency department with 4 victims whose clothes are saturated with a strong-smelling liquid.  The victims are wheezing.  The nurse should implement which intervention first?

When assessing the client's pain level, what will the nurse determine is the most reliable indicator of the pain?

A nurse is reviewing the most recent laboratory results of a client on the telemetry floor.  The client is currently asymptomatic, and the telemetry monitor indicates sinus rhythm.  Which of the following critical values is mostlikely due to laboratory error?