Exam 4: Fundamentals

The nurse is reinforcing instructions to a client on collection of a sputum specimen for culture and sensitivity.  Which of the following client statements indicate that teaching has been effective?  Select all that apply.

The nurse admits an 80-year-old client with an altered level of consciousness and left-sided weakness following a recent stroke.  The client is dehydrated from multiple episodes of diarrhea.  Which interventions should the nurse implement to prevent falls?  Select all that apply.

The emergency department nurse receives report on 4 clients.  Which client will the nurse prioritize for placement in an isolation room?

Which interventions does the nurse perform to promote normal rest and sleep patterns for a critically ill client?  Select all that apply.

The community health nurse is preparing to teach a group of African American women about prevention of diseases common to their ethnic group.  Based on the incidence of disease within this group, which disorders should the nurse plan to discuss?  Select all that apply.

The nurse is caring for a 2-year-old who is refusing oral antibiotics.  What is the nurse's next action?

A new graduate nurse is preparing to administer the following analgesics to clients with postoperative pain.  Which situation would require intervention by the precepting nurse?

A legally blind client is being prepared to ambulate 1 day after an appendectomy.  What is the most appropriate action by the nurse?

A client with advanced multiple sclerosis (MS) has been a resident in a nursing home for the past 2 years.  One day, the client tells the nurse, "I want to get out of here and try living in my own home."  What is the best response by the nurse?

The nurse is caring for a client with advanced Alzheimer disease.  Which techniques are appropriate when speaking with this client?  Select all that apply.

The nurse plans care for a client who has a positive Romberg test.  The nurse will prioritize which intervention?

A home health nurse is visiting a 72-year-old client who had coronary artery bypass graft surgery 2 weeks ago.  The client reports being forgetful and becoming teary easily.  How should the nurse respond?

A nurse is caring for a client who is meeting with the palliative care team.  After the meeting, the client's family asks for clarification about palliative care.  Which statements about palliative care are accurate?  Select all that apply.

The nurse is preparing to administer several medications through a client's feeding tube.  None of the medications are extended release.  Which of the following actions should the nurse implement?  Select all that apply.

A client on hospice home care is taking sips of water but refusing food.  Family members appear distressed and insist that the personal care worker "force feed" the client.  What is the priority nursing action?

The public health nurse conducts a program at the community senior citizen center about preventing falls at home.  Which statement made by a participant indicates that further education is needed?

The nurse is caring for a client newly prescribed crutches.  Which finding indicates the need for further teaching?

A new nurse attends a risk management class on the indications and legal implications of using chemical restraints to maintain client safety.  Which prescription should the nurse question before administering?

Before examining the infant of a Mexican American mother, the nurse compliments the child's outfit.  The mother becomes visibly distressed.  What is the best next action for the nurse to take?

A client who is 24 hours postoperative bowel resection is receiving IV opioids PRN for severe pain.  The nurse reviews the health care provider's prescription to discontinue the continuous IV normal saline.  What is the nurse's most appropriate action?