Fundamentals 2023 Proctor Part 1

A nurse is assisting with the care of a client who has a prescription for IV therapy. The client tells the nurse that he has numerous allergies. Which of the following allergies should the nurse bring to the attention of the charge nurse prior to the initiation of the therapy?

eggs
latex
seafood
bee stings

A nurse is caring for a client who has a prescription for a high-protein diet to
promote wound healing following surgery. The client's religion prohibits eating
meat on particular days. Which of the following actions should the nurse take?
a. encourage the client to eat meat during this time to promote healing
b. advise the client to eat everything on the tray except the meat
c. suggest the client receive high-protein enteral feedings
d. ask the dietitian to recommend alternative food choices for the client

A nurse is caring for a client who has prescription for a high-protein diet to promote wound healing following surgery. The client's religion prohibits eating meat on particular days. Which of the following actions should the nurse take?

Encourage the client to eat meat during this time to promote healing
Advise the client to eat everything on the tray except the meat
Suggest the client receive high-protein enteral feedings
Ask the dietitian to recommend alternative food choices for the clie

A nurse is collecting data from a client who is 2 days postoperative following a
colostomy. Which of the following findings should the nurse report to the
provider?
a purple-colored stoma
protrusion of the stoma
a small amount of bleeding from the stoma
intestinal gas in the pouch

A nurse is reinforcing teaching with a client about self-administration of
ophthalmic drops. Which of the following instructions should the nurse include?

"You will need to look to the side when you put the drops in your eye."
"You should put the drops directly in the center of your eyeball."
"You should cleanse your eye from the inner to the outer edge prior to putting in
the drops."
"You should avoid pressing on your tear duct after putting the drops in your eye."

A nurse is reinforcing teaching about carbohydrate counting with a client who has
a new diagnosis of diabetes mellitus. Which of the following actions should the
nurse take first?
a. use pictures of different food groups to help the client plan a daily menu
b. ask the client what he already knows about meal planning
c. give the client a brochure with sample menus for all meals
d. involve the family in the discussion of the client's meal plan

A nurse is assisting with the admission of an adult client to a medical-surgical unit. Which of the following findings should the nurse identify as an indication that the client is malnourished?

heart rate 89/min
pink mucous membranes
pale, scaly skin
body mass index 23

A nurse is reinforcing teaching about advance directives with a client who has end-
stage renal disease. Which of the following client statements indicates an
understanding of the teaching?
a. "I know that i can change my advance directives if I need to in the future."
b. "My health care proxy will make my health care decisions as soon as I have
signed the power of attorney."
c. "My family can overrule the decisions made by my health care proxy."
d. "Advance directives from one state are valid in any other state."

A nurse is preparing a client for a Romberg test. Which of the following statements should the nurse make?

"Stand with your feet together and your arms at your sides."
"After I place the tuning fork, tell me when you no longer hear the sound"
"I'm going to stroke the lateral side of the bottom of your foot."
"Touch each fingertip as quickly as possible with your thumb."

A nurse is contributing to the plan of care for a client who is dying. Which of the following interventions should the nurse recommend to include the client's family in the plan of care? (Select all that apply.)

keep the family updated about the client's status
Suggest the family members return home at night to allow the client to rest
encourage the family to comb the clients hair
tell the client's family what to expect as the client's death nears
ask the family to encourage the client to eat

A nurse is checking a client for a pulse deficit after detecting an irregular heart rate. Which of the following actions should the nurse take?
count the client's radial and apical pulses simultaneously with another nurse.
calculate the client's pulse for 30 seconds and multiply by 2
assist the client to a side-lying position
auscultate the area of the client's chest over the Erb's point

A nurse is reinforcing teaching with a client who is scheduled for a bladder scan. Which of the following instructions should the nurse include in the teaching?

"You will need to sign a consent form before we begin the procedure."
"I will place a gel pad directly above your pubic area before I place the probe."
"You will need to hold your urine for 1 hour prior to the procedure."
"You will receive a contrast dye through an IV catheter prior to the scan."

A charge nurse is reinforcing teaching with a newly licensed nurse who is setting up a sterile field. Which of the following actions by the newly licensed nurse indicates an understanding of the teaching?

opening the first flap of a sterile package toward herself
dropping sterile gauze onto the field from a height of 7.5 cm (3 in)
removing and inverting a lid before placing it onto a nonsterile surface
maintaining the sterile field below waist level.

A nurse is caring for a client who has been vomiting excessively and has diarrhea. Which of the following findings should the nurse identify as an indication of fluid
volume deficit?

BUN 18 mg/dL
a bounding pulse
urine specific gravity 1.045
prominent neck veins

A nurse is providing care to four clients in an acute care setting. The nurse should identify that which of the following client statements presents and ethical dilemma?
"I might file a lawsuit because of how my surgery went."
"Please don't tell my doctor, but I am taking my partner's oxycodone."
"Please don't get me out of bed this morning. It hurts too much."
"I don't want to take my medicine. It makes me sick to my stomach."

A nurse is preparing to document information about a client's lower legs, which are swollen with 6 mm edema. Which of the following information should the nurse
document?

1+ pitting edema
2+ pitting edema
3+ pitting edema
4+ pitting edema

A nurse manager is reinforcing teaching with a group of newly licensed nurses about the disclosure of client health information. The nurse can disclose health information without the client's written permission to which of the following
entities?

an insurance agency offering a life insurance policy
a family member who requests the client's diagnosis
a physical therapist who is involved in the client's care
an employer completing a pre-employment screening

A nurse is preparing to remove staples from a client's incision. Which of the following actions should the nurse take?

lift the staple remover when squeezing the handle
avoid completely closing the handle after squeezing
expect the staple to bed at each outer side of the staple
remove the staple from the skin after both sides are visible

A nurse is reinforcing teaching with a client who has hypertension and a
prescription to measure her blood pressure daily. Which of the following client
statements indicates an understanding of the teaching?
a. "I will wait 15 minutes after drinking coffee to measure my blood pressure."
b. "I will measure my blood pressure while my arm is elevated above my heart."
c. "I should remove constrictive clothing prior to measuring my blood pressure."
d. I should measure my blood pressure immediately after eating breakfast."

A nurse is contributing to the plan of care for four clients. For which of the following clients should the nurse initiate airborne precautions?

a client who has pneumonia
a client who has measles
a client who has pertussis
a client who has methicillin-resistant Staphylococcus aureus (MRSA)

A nurse is contributing to the plan of care for a client who practices Islam. Which of the following questions should the nurse ask the client to clarify her religious preferences?

"Do you receive Holy Communion?"
"Do you follow a kosher diet?"
"Do you consume pork products?"
"Do you oppose receiving a blood transfusion if it is needed?"

A nurse is reinforcing teaching with a client who has insomnia. Which of the following statements by the client indicates an understanding of the teaching?

"I should turn on the ceiling fan to block out unwanted noise."
"I will limit my daily nap to 45 minutes."
"I will drink a cup of green tea at bedtime to help me sleep."
"I should get out of bed if I don't fall asleep within an hour of lying down."

A nurse is caring for a client who has a new prescription for oxygen at 7 L/min via simple face mask. Which of the following actions should the nurse take to ensure client safety?

keep the side holes of the mask closed
ensure the reservoir bag is inflated on expiration
apply petroleum jelly to the clients nostils
attach a humidifier to the base of the flow meter

A nurse is caring for four clients. For which of the following clients should the nurse use the therapeutic communication technique of silence?

a client who plans to leave the facility against medical advice
a client who informs the nurse that he has made his funeral arrangements
a client who tells the nurse that the night shift nurse did not bring his medication
a client who has just experienced the death of his child

A nurse is caring for a client who has an indwelling urinary catheter. Which of the following actions should the nurse take?

clean the perineal area at least once a day
empty the drainage bag when it is three-fourths full
flush the catheter with sterile water daily
disconnect the drainage bag when emptying and measuring urine

A nurse is caring for a client who is receiving chemotherapy and has stomatitis. Which of the following actions should the nurse take to reduce the client's discomfort?

offer the client lemon-glycerin swabs
encourage the client to drink hot tea
use 0.9% sodium chloride solution to rinse the client's mouth
provide a commercial mouthwash for the client's oral care

A nurse is reinforcing teaching with the partner of a client who is immobile. Which of the following instructions should the nurse give the partner about turning the client in bed?

"Keep your feet close together."
"Tighten your stomach muscles."
"Straighten your knees."
"Bend at your waist."

A nurse is caring for an older adult client and is concerned that the client may have a fecal impaction. Which of the following is the most important question for the nurse to ask?

"What types of foods have you been eating?"
"Are you using stool softeners or laxatives?"
"Have you been passing gas?"
"Have you had small liquid stools?"

A nurse is working in a hospital overhears the following conversation between two other nurses on the elevator. Which of the following actions should the nurse take?

inform the nurses that the neighbor's dog did not cause the wound
tell the nurses that this conversation is not appropriate
complete an incident report upon returning to the unit
report the nurses' conversation to the client's provider

A nurse is caring for a client who has chronic kidney disease. The nurse should identify that which of the following findings is the priority?

client reports voiding three times during the night
client reports burning and discomforting with urination
the client's WBC count is 11,000/mm^3
the client's output was 60 mL for the past 3 hr

A nurse is planning to administer medication to a client who has a Clostridium difficile infection. Which of the following actions should the nurse plan to take to prevent the transmission of this infection to others?

Clean hands with an alcohol-based hand rub immediately after removing gloves.
Remove the cover gown in the client's room after providing care. Place the client in a room with negative-pressure airflow
Wear a mask when administering oral medications to the client.

A nurse is reinforcing teaching with a client who is scheduled for a bladder scan. Which of the following instructions should the nurse include in the teaching?

"You will need to sign a consent form before we begin the procedure."
"I will place a gel pad directly above your pubic area before I place the probe."
"You will need to hold your urine for 1 hour prior to the procedure."
"You will receive a contrast dye through an IV catheter prior to the scan."

A nurse is checking a client for a pulse deficit after detecting an irregular heart rate. Which of the following actions should the nurse take?

Count the client's radial and apical pulses simultaneously with another nurse.
Calculate the client's pulse for 30 seconds and multiply by 2.
Assist the client to a side-lying position.
Auscultate the area of the client's chest over the Erb's point.

A nurse is preparing to obtain a clients vital signs. Which of the following actions should the nurse take when washing their hands?

Rinse their forearms with running water before applying soap.
Hold their hands above elbow level while washing and rinsing.
Generate a lather by rubbing their hands together vigorously for 5 seconds.
Turn off the faucet with a clean paper towel after drying hands.

A nurse is preparing to perform a wound irrigation for a client who has a stage 3 pressure injury. Which of the following supplies should the nurse plan to use?

A piston syringe.
Barrier ointment.
Chilled irrigation solution.
Sterile cotton balls.