Exam 4: Fundamentals

The nurse prepares to draw up regular and NPH insulins into one syringe.  Place in order the steps the nurse should take when mixing the insulins.  All options must be used.

A nurse is caring for a client with blindness due to diabetic retinopathy.  Which interventions should the nurse implement for this client?  Select all that apply.

The nurse is caring for a pregnant client with a positive urine drug screen.  When questioned about substance abuse, the client begins to throw objects at the nurse and yells, "I'm leaving this hospital right now before you call the police on me!"  What is the best response by the nurse?

A client who is intubated and on mechanical ventilation is receiving continuous enteral tube feedings at 30 mL/hr via a small-bore nasogastric tube.  Which actions should the nurse take to prevent aspiration in this client?  Select all that apply.

A client diagnosed with hypertension has been prescribed a clonidine patch.  Which instructions should the nurse include?  Select all that apply.

The nurse is teaching a client of American Indian heritage how to self-administer insulin.  As the nurse describes the necessary steps in the injection process, the client continuously avoids eye contact and occasionally turns away from the nurse.  Which action is most appropriate for the nurse to take in this situation?

The unit educator is performing skill validations with unit staff.  Which of the following actions by the staff nurses demonstrate a correct understanding of parenteral medication administration?  Select all that apply.

A Muslim woman is admitted to the inpatient trauma unit after falling and sustaining a head injury.  In providing culturally competent care for this client, which consideration is most important?

The nurse is preparing an injection of IM haloperidol from a glass ampule.  Which of the following actions by the nurse are appropriate?  Select all that apply.

The nurse in the intensive care unit (ICU) is giving unlicensed assistive personnel (UAP) directions for bathing a client who has a surgical incision infected with methicillin-resistant Staphylococcus aureus (MRSA).  Which instructions would be most effective for reducing infection?

The nurse prepares to insert an indwelling urinary catheter in a client who is disoriented to time, place, and person and cannot follow directions or commands.  Which intervention is most important when inserting the urinary catheter?

The charge nurse in the telemetry unit has delegated the task of giving a bed bath to a male Arab client who practices traditional Islamic customs.  Which communication to the female nursing assistant demonstrates appropriate cultural sensitivity to this client?

The registered nurse (RN) and licensed practical nurse (LPN) are caring for several clients.  The RN delegates client positioning to the LPN.  While evaluating the delegated task, the RN realizes that which client positions require intervention?  Select all that apply.

A client is receiving a blood transfusion.  Fifteen minutes after the transfusion starts, the nurse notes a drop in blood pressure from 110/70 to 84/50 mm Hg.  The client reports "feeling a little cold."  Based on this assessment, in what order should the nurse complete the following actions?  All options must be used.

The nurse is caring for 4 clients requiring IV fluid therapy.  For which client should the nurse anticipate the need for isotonic crystalloid administration?

The nurse enters a client's room and finds that the client and spouse are crying.  The spouse states that the health care provider just diagnosed the client with Alzheimer disease.  What is the best response by the nurse?

The unlicensed assistive personnel (UAP) reports finding a reddened area on a client's sacrum during a bath.  What is the nurse's priority action?

As the nurse begins to assist with ambulation of a 9-year-old who is one day post appendectomy, the child cries out, "It hurts too much.  I can't do it."  What is the first action by the nurse?

A graduate nurse is caring for a client with a triple-lumen peripherally inserted central catheter in the right arm.  Which actions by the graduate nurse indicate that more education is needed?  Select all that apply.

An elderly client with end-stage renal disease who has refused dialysis is admitted to a long-term care facility for rehabilitation following hospitalization.  The next day, the client becomes agitated and says to the nurse, "I've got to get back home to my things.  I have so much to do."  Which is the most likely interpretation of this client's behavior?