Exam 4: Fundamentals

A postoperative client who is receiving continuous enteral feedings via a nasoenteric tube becomes dyspneic with a productive cough, and the nurse auscultates crackles and diminished breath sounds in lung bases.  Which action is appropriate at this time?

The nurse learns that an Orthodox Jewish client has not started taking recently prescribed diltiazem extended-release capsules.  The client states "I cannot take the medication in this form."  What is the nurse's first action?

The family of a terminally ill, dying client verbalizes concern that the client is becoming dehydrated due to poor fluid intake.  When the family asks the nurse about administering IV fluids, the nurse's response is based on an understanding of which statement?

The nurse is caring for a client who performs frequent urinary self-catheterizations.  Which of the following client assessments would indicate a potential for a latex allergy?  Select all that apply.

A 7-year-old client receives a scalp laceration to the back of the head while on a playground, and the new nurse prepares to irrigate the wound.  Which actions by the new nurse would require the experienced nurse to intervene?  Select all that apply.

The nurse will anticipate administration of isotonic IV fluids in which clients?  Select all that apply.

The nurse is caring for a client with Clostridium difficile colitis.  Which of the following infection control measures by the nurse are appropriate?  Select all that apply.

The nurse is caring for an 83-year-old bedridden client experiencing fecal incontinence.  Which nursing intervention is the highest priority for this client?

A 55-year-old client on a medical-surgical unit has just received a diagnosis of pancreatic cancer.  The client says to the nurse, "Is this disease going to kill me?"  What is the best response by the nurse?

A client has just returned to the room after having a mammogram.  The client is teary and in a shaky voice says to the nurse, "The radiology technician told me that it looks really bad - the tumor in my breast is very large."  Which is the best response by the nurse?

The nurse is interviewing a non-English-speaking client.  Which best practices will the nurse use when working with a professional medical interpreter for clients of limited English proficiency?  Select all that apply.

The 70-year-old client with type 2 diabetes and hypertension is scheduled for ureteral stent removal in 2 hours.  The preoperative protocol ECG is done in the inpatient unit, and results indicate a "possibly acute" ST segment elevation.  What action is most important for the nurse to take?

The charge nurse is notified that a client is being admitted with a diagnosis of active shingles with a disseminated rash.  Which room assignment is most appropriate for this client?

The nurse is conducting a home visit to assess an elderly client with advanced heart failure who lives alone.  When the nurse asks about sodium intake, the client becomes angry and says, "I'm so tired of people telling me what to do!  I'm going to eat what I want, so leave me alone!"  Which of the following is the most appropriate response by the nurse?

A nurse is caring for a client who is intubated and has a subclavian central venous catheter.  Which nursing intervention is most important to prevent the spread of infection to this client?

The nurse initiates prescribed intravenous (IV) therapy on an 86-year-old hospitalized client.  Which life span concept(s) should be considered when initiating IV therapy and caring for an older adult receiving IV therapy?  Select all that apply.

The nurse attempts to flush a client's subclavian vein central venous access device with normal saline using a 10-mL syringe, but meets resistance, is unable to aspirate blood, and suspects an occlusion.  What should the nurse do next?

The nurse caring for a client diagnosed with HIV uses which infection prevention and control measures?  Select all that apply.

An adolescent client is brought to the emergency department after being in a serious motor vehicle crash.  The client is undergoing cardiopulmonary resuscitation.  The nurse calls the family to inform them to come to the hospital and a family member asks how the client is doing.  Which is an example of the ethical principle of beneficence when responding to the client's family?

A nurse in the surgical admitting unit is preparing a client for elective coronary artery bypass surgery.  Which statement by the client should the nurse report immediately to the health care provider (HCP)?