Exam 4: Fundamentals

A client with acute ST-elevation myocardial infarction intends to leave the hospital now against medical advice (AMA) regardless of what is recommended.  The client is determined to be competent to make personal decisions.  Which of the following is the most important for the nurse to do before the client leaves the building?

A client with a dislocated shoulder is prescribed a shoulder sling.  The nurse applies the sling and evaluates the fit before discharge from the emergency room.  Which assessment finding indicates an incorrect fit?

The nurse should consider which of the following client reports as an indication of an allergic reaction?

The nurse is administering cleansing enemas to a client the night before bowel surgery.  During instillation of the enema, the client reports cramping and pain.  What action should the nurse take?

The registered nurse observes a graduate nurse who is inserting a small-bore nasojejunal feeding tube.  Which action by the graduate nurse requires intervention by the registered nurse?

The nurse is instructing a female client how to collect a clean catch urine specimen.  Place in order the steps indicating that client teaching has been effective.  All options must be used.

A nurse is teaching a parent of an infant about administration of an oral medication.  What should be included in the teaching?  Select all that apply.

The nurse prepares to administer an IV infusion of potassium chloride through a peripheral vein to a client with hypokalemia.  The health care provider's prescription states: IV potassium chloride 10 mEq (10 mmol)/100 mL 5% dextrose in water now, infuse over 30 minutes.  What is the nurse's priority action?

A client with suspected foot osteomyelitis is scheduled for an MRI.  Which findings should the nurse notify the health care provider about before the test?  Select all that apply.

The registered nurse (RN) is providing nursing care with a licensed practical nurse and unlicensed assistive personnel.  The RN administers hydromorphone 1.5 mg IVP per STAT order to a client with severe abdominal pain.  Three hours later, the client rates pain as a 9 on a scale of 0-10 and requests pain medication.  What is the most appropriate action for the RN to take?

Which client incident would be classified as an adverse event that requires an incident/event/irregular occurrence/variance report?  Select all that apply.

A nurse prepares a client for knee arthroscopy requiring general anesthesia.  Which actions should the nurse complete?  Select all that apply.

The nurse helps the health care provider perform a thoracentesis at the bedside.  In which position does the nurse place the client to facilitate needle insertion and promote comfort?

A school nurse observes a 3-year-old begin to choke and turn blue while eating lunch.  What should be the nurse's initial action?

The hospice nurse is providing end-of-life care to a client who is experiencing anorexia and cachexia.  Which interventions are appropriate?  Select all that apply.

An elderly client is brought to the emergency department with lethargy, chills, and sharp chest pain with deep breathing.  Pulse oximeter shows 93% on room air and respirations are 24/min.  What is the nurse's initial action?

A client in the mental health unit picks up a fire extinguisher and throws it at a nurse standing by the nurses' station.  What is the most important intervention by the nurse?

The nurse removes personal protective equipment (PPE) after completing a wound dressing change for a client in airborne transmission-based precautions.  Which PPE should the nurse remove first?

The nurse plans to administer 9:00 AM medications via the nasogastric (NG) route to a client with an NG tube.  The nurse contacts the primary health care provider (PHCP) to clarify which prescriptions that are contraindicated using this route?  Select all that apply.

The nurse cares for a confused client who continues to pull at the intravenous (IV) catheter on the left forearm despite frequent instructions not to do so.  What is the nurse's next action?