Fundamentals 2023 Proctor Part 2

A nurse is caring for a client who has dyspnea caused by a respiratory infection. The nurse should assist the client into which of the following positions.

Orthopneic.
Dorsal recumbent.
Sims'
Prone

A nurse in 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?

Use pictures of different food groups to help the client plan a daily menu.
Ask the client what they already know about meal planning.
Give the client a brochure with sample menus for all meals.
Involve the family in the discussion of the client's meal plan.

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 client's nostrils.
Attach a humidifier to the base of the flow meter.

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 the client's 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 caring for a client who has limited mobility. Which of the following actions should the nurse take to maintain the client's skin integrity?

Use warm water when bathing the client.
Place a donut shaped cushion in the client's chair.
Massage reddened areas over bony prominences.
Maintain the client in high-Fowler's position.

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 they have made their funeral arrangements.
A client who tells the nurse that the night shift nurse did not bring their
medication.
A client who has just experienced the death of their child

A nurse is caring for a group of clients in a long-term care facility. Which of the
following actions should the nurse take to prevent health care-associated infections
for these clients? (Select all that apply)
-Place immunocompromised clients in the same room.
-Wash hands after removing gloves.
-Use antimicrobial hand gel after refilling a client's water pitcher
-Clean the stethoscope with an antimicrobial wipe after obtaining vital signs.
-Administer a prophylactic dose of antibiotics prior to discharge.

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

BUN 18 mg/dL.
A thready pulse.
Hemoglobin 15 g/dL.
Prominent neck veins.

A nurse is planning care for a group of clients. The nurse should expect to witness an informed consent for a client who will undergo which of the following procedures?

Administration of an enema.
Performance of a paracentesis.
Insertion of an indwelling urinary catheter.
Placement of an NG tube.

A nurse working in a community clinic is talking with an older client who states that their life has no purpose. The nurse should identify that the client is in which of the following stages of Erikson's Theory of Psychosocial Development?

Ego integrity vs. despair
Generativity vs. self-absorption
Identity vs. role confusion
Intimacy vs. isolation

A nurse is caring for a client who has chronic pain. The nurse recommends that the client concentrate on a memory of a pleasurable experience. Which of the following complementary therapies is the nurse suggesting?

Art therapy.
Tai chi.
Guided imagery.
Biofeedback.

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?

"I know that I can change my advance directives if I need to in the future."
"My health care surrogate will make my health care decisions as soon as I have signed the power of attorney."
"My family can overrule the decisions made by my health care surrogate."
"Advance directive from one state are valid in any other state."

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 an 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 caring for a client who has a new diagnosis of cancer. Which of the following actions by the nurse maintains the client's confidentiality?

Sharing the client's prognosis with a member of the client's family.
Discussing the client's status with a member of the spiritual support team.
Collaborating with a nurse from another unit about the client's care.
Providing client information to another nurse at change of shift.

A nurse and an assistive personnel (AP) are providing postmortem care for a decease client prior to visitation by the family. Which of the following actions by the AP requires intervention by the nurse?

Fathering the client's personal belongings.
Removing the client's dentures.
Placing absorbent pads under the client's buttocks.
Closing the client's eyes.

A nurse reinforcing teaching with a client who has pneumonia and a productive cough. Which of the following instructions should the nurse include in the teaching?

"Your visitors should wear a protective gown."
"You should receive a pneumonia vaccine every year."
"You should stand 1 foot away from others when coughing."
"You should cover your mouth with a tissue when you cough."

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 collecting data from a client who is 2 days postoperative following a colostomy placement. 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 collecting data from a client who is 1 day postoperative following abdominal surgery. Which of the following findings is the priority for the nurse to report to the provider?

The client reports incisional pain as 7 on a scale of 0-10.
The client reports increased nausea and chills.
The client has an oral temperature of 38.5° (101.3° F).
The client has tenderness and warmth in their calf.

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 turning 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 intervention 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 that family members return home at night to allow the client to rest.
-Encourage the family to comb the client's 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 caring for a client who reports difficulty sleeping at home. Which of the following recommendations should the nurse provide to promote a restful home sleep environment?

"Perform muscle relaxation before bedtime."
"Exercise vigorously 1 hour prior to going to bed."
"Drink a cup of hot chocolate at bedtime."
"Change the time you go to sleep each day.

A nurse is reinforcing teaching with a new parent who is concerned about sudden infant death syndrome (SIDS). Which of the following statements by the client indicates an understanding of the teaching?

"I will place my baby on her side to sleep."
"I should avoid giving my baby a pacifier."
"I will remove all stuffed animals from my baby's crib."
"I will cover my baby with a light blanket when she is sleeping."

A nurse is providing oral hygiene for a client who is unconscious. Identify the sequence of the steps the nurse should take. (Move the steps into the box in order of performance)

-Place a towel under the client's head with an emesis basin under their chin.
-Assess the client's gag reflex.
-Cleanse the client's mouth using a toothbrush.
-Separate the client's upper and lower teeth with an oral airway device.
-Position the client on their side with their head turned to the side.

A nurse is caring for a client who is receiving intermittent enteral feedings. Which of the following is the first action the nurse should take?

Measure the client's gastric residual before each feeding.
Change the bag and tubing every 24 hours.
Document intake and output.
Flush the tubing with 30 mL of water after each feeding.

A nurse is in a long-term care facility in collecting admission data from a client who uses a hearing aid. Which of the following actions should the nurse take?

Sit beside the client.
Speak slowly and loudly.
Dim the lights in the client's room.
Choose a private room for the interview.

A nurse manager is reinforcing teaching with a group of newly licensed nurses about the disclosure of client health information. A nurse can disclose health information without the client's written permission to which 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 demonstrating the use of a transparent film dressing over a client's superficial wound. Which of the following information about a transparent film dressing should the nurse include?

"This dressing keeps the wound bed dry."
"This dressing allows the wound bed to breathe."
"This dressing requires a secondary dressing."
"This dressing requires

A nurse is collecting data from a client following a lumbar puncture. The nurse should identify which of the following findings as a potential adverse effect of this procedure?

Fluid Overload
Diarrhea
Headache
Difficulty voiding

A nurse is evaluating the crutch-walking technique of a client who is required to keep weight off their right leg. Which of the following is the proper crutch gait for this client?

Four-point
Three-point
Two-point
Swing-through

A nurse assisting with the admission of a 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.
Pallor with scaly skin.
Body mass index 23

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 postoperative following a mastectomy. The client states, "I can barely look at myself in the mirror." The nurse should identify that the client is experiencing which of the following?

Complicated grief.
Maturational loss.
Disenfranchised grief.
Actual loss.

A nurse is caring for a client who is scheduled for surgery the following day. During the night, the client is unable to sleep and is restless. Which of the following statements should the nurse make?

"It must be difficult facing this type of surgery."
"Other clients who have had this surgery have done just fine."
"This facility is known for providing excellent care for people who need this type of surgery."
"I can request a sleeping pill, if you think that will help."

A nurse is caring for a client who reports itching 30 min after receiving a newly prescribed medication. Which of the following data should the nurse document in the client's medical record?

Client is itching from medication.
Client states, "I started to itch after taking that medication."
It appears that the client has a rash from the medication.
Rash from medication noted.