Fundamentals Quiz PDF

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Hesi review with questions for RN ...

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Fundamentals B Quiz. (Hesi) 1. The home health nurse visits an elderly female client who had a brain attack three months ago and is now able to ambulate with the assistance of a quad cane. Which assessment finding has the greatest implications for this client's care? • • • •

The husband, who is the caregiver, begins to weep when the nurse asks how he is doing. The client tells the nurse that she does not have much of an appetite today. The nurse notes that there are numerous scatter rugs throughout the house. Correct The client's pulse rate is 10 beats higher than it was at the last visit one week ago.

Scatter rugs (C) pose a safety hazard because the client can trip on them when ambulating, so this finding has the greatest significance in planning this client's care. Psychological support of the caregiver (A) is a less acute need than that of client safety. The nurse needs to obtain more information about (B), but this is not a safety issue. (D) is not a significant increase, and additional assessment might provide information about the reason for the increase (anxiety, exercise, etc.). 2. The nurse is digitally removing a fecal impaction for a client. The nurse should stop the procedure and take corrective action if which client reaction is noted? • • • •

Temperature increases from 98.8° to 99.0° F. Pulse rate decreases from 78 to 52 beats/min. Correct Respiratory rate increases from 16 to 24 breaths/min. Blood pressure increases from 110/84 to 118/88 mm/Hg.

Parasympathetic reaction can occur as a result of digital stimulation of the anal sphincter, which should be stopped if the client experiences a vagal response, such as bradycardia (B). (A, C, and D) do not warrant stopping the procedure. 3. The nurse is providing passive range of motion (ROM) exercises to the hip and knee for a client who is unconscious. After supporting the client's knee with one hand, what action should the nurse take next? •

Raise the bed to a comfortable working level.

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Bend the client's knee.

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Move the knee toward the chest as far as it will go.

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Cradle the client's heel. Correct

Passive ROM exercise for the hip and knee is provided by supporting the joints of the knee and ankle (D) and gently moving the limb in a slow, smooth, firm but gentle manner. (A) should be done before the exercises are begun to prevent injury to the nurse and client. (B) is carried out after both joints are supported. After the knee is bent, then the knee is moved toward the chest to the point of resistance (C) two or three times. TestBankWorld.org

4. A client who has moderate, persistent, chronic neuropathic pain due to diabetic neuropathy takes gabapentin (Neurontin) and ibuprofen (Motrin, Advil) daily. If Step 2 of the World Health Organization (WHO) pain relief ladder is prescribed, which drug protocol should be implemented? • • • •

Continue gabapentin. Correct Discontinue ibuprofen. Add aspirin to the protocol. Add oral methadone to the protocol.

Based on the WHO pain relief ladder, adjunct medications, such as gabapentin (Neurontin), an antiseizure medication, may be used at any step for anxiety and pain management, so (A) should be implemented. Nonopiod analgesics, such as ibuprofen (A) and aspirin (C) are Step 1 drugs. Step 2 and 3 include opioid narcotics (D), and to maintain freedom from pain, drugs should be given around the clock rather than by the client s PRN requests. 5. The nurse is preparing to irrigate a client's indwelling urinary catheter using an open technique. What action should the nurse take after applying gloves? • • • •

Empty the client's urinary drainage bag. Draw up the irrigating solution into the syringe. Correct Secure the client's catheter to the drainage tubing. Use aseptic technique to instill the irrigating solution.

To irrigate an indwelling urinary catheter, the nurse should first apply gloves, then draw up the irrigating solution into the syringe (B). The syringe is then attached to the catheter and the fluid instilled, using aseptic technique (D). Once the irrigating solution is instilled, the client's catheter should be secured to the drainage tubing (C). The urinary drainage bag can be emptied (A) whenever intake and output measurement is indicated, and the instilled irrigating fluid can be subtracted from the output at that time. 6. Which client care requires the nurse to wear barrier gloves as required by the protocol for Standard Precautions? • • • •

Removing the empty food tray from a client with a urinary catheter. Washing and combing the hair of a client with a fractured leg in traction. Administering oral medications to a cooperative client with a wound infection. Emptying the urinary catheter drainage bag for a client with Alzheimer's disease. Correct

Possible contact with body secretions, excretions, or broken skin is an indication for wearing barrier (nonsterile) gloves. Emptying a urine drainage bag requires the use of gloves (D). (A, B, and C) do not require gloves. 7. What action should the nurse implement to prevent the formation of a sacral ulcer for a client who is immobile?

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Maintain in a lateral position using protective wrist and vest devices. Position prone with a small pillow below the diaphragm. Correct Raise the head and knee gatch when lying in a supine position. Transfer into a wheelchair close to the nurse's station for observation.

The prone position (B) using a small pillow below the diaphragm maintains alignment and provides the best pressure relief over the sacral bony prominence. Using protective (restraining) devices (A) is not indicated. Raising the head and bed gatch (C) may reduce shearing forces due to sliding down in bed, but it interferes with venous return from the legs and places pressure on the sacrum, predisposing to ulcer formation. Sitting in a wheelchair (D) places the body weight over the ischial tuberosities and predisposes to a potential pressure point. 8. What intervention should the nurse include in the plan of care for a client who is being treated with an Unna's paste boot for leg ulcers due to chronic venous insufficiency? • • • •

Check capillary refill of toes on lower extremity with Unna's paste boot. Correct Apply dressing to wound area before applying the Unna's paste boot. Wrap the leg from the knee down towards the foot. Remove the Unna's paste boot q8h to assess wound healing.

The Unna's paste boot becomes rigid after it dries, so it is important to check distally for adequate circulation (A). Kerlix is often wrapped around the outside of the boot and an ace bandage may be used to cover both, but no bandage should be put under it (B). The Unna's paste boot should be applied from the foot and wrapped towards the knee (C). The Unna's paste boot acts as a sterile dressing, and should not be removed q8h. Weekly removal is reasonable (D). 9. The nurse is administering an intermittent infusion of an antibiotic to a client whose intravenous (IV) access is an antecubital saline lock. After the nurse opens the roller clamp on the IV tubing, the alarm on the infusion pump indicates an obstruction. What action should the nurse take first? • • • •

Check for a blood return. Reposition the client's arm. Correct Remove the IV site dressing. Flush the lock with saline.

If the client's elbow is bent, the IV may be unable to infuse, resulting in an obstruction alarm, so the nurse should first attempt to reposition the client's arm to alleviate any obstruction (B). After other sources of occlusion are eliminated, the nurse may need to check for a blood return (A), remove the dressing (C), or flush the saline lock (D) and then resume the intermittent infusion. 10. A female client who has breast cancer with metastasis to the liver and spine is admitted with constant, severe pain despite around-the-clock use of oxycodone (Percodan) and amitriptyline (Elavil) for pain control at home. During the admission assessment, which information is most important for the nurse to obtain? •

Sensory pattern, area, intensity, and nature of the pain. Correct TestBankWorld.org

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Trigger points identified by palpation and manual pressure of painful areas. Schedule and total dosages of drugs currently used for breakthrough pain. Sympathetic responses consistent with onset of acute pain.

The components of every pain assessment should include sensory patterns, area, intensity, and nature (PAIN) of the pain (A) and are essential in identifying appropriate therapy for the client's specific type and severity of pain, which may indicate the onset of disease progression or complications. Triggers (B), current drug usage (C), and sympathetic responses (D), such as tachycardia, diaphoresis, and elevated blood pressure, are important, but should be obtained after focusing on (A). 11. A male client is on contact precautions due to an infected draining wound and is being discharged home. The client lives at home with his wife and their adolescent daughter. What discharge instruction should the nurse include for the client? • • • •

Use disposable plates and utensils. Stay in a room with the door closed. Dispose of soiled dressings in plastic bags that are securely closed. Correct Others who are in the same room with the client should wear a mask.

Contact precautions require the use of a barrier that prevents contact with wound secretions on soiled dressings, which are best disposed of in tightly closed plastic bags (C). (A) is not necessary with contact precautions. (B and D) should be implemented for airborne, droplet precautions, or protective environments. Category: Fundamentals 12. The nurse is discussing dietary preferences with a client who adheres to a vegan diet. Which dietary supplement should the nurse encourage the client to include the dietary plan? • • • •

Fiber. Folate. Ascorbic acid. Vitamin B12. Correct

Vitamin B12 is normally found in liver, kidney, meat, fish and dairy products. A vegan who consumes only vegetables without careful dietary planning and supplementation may develop peripheral neuropathy due to a deficiency in vitamin B12 (D). (A, B, and C) are commonly adequate in vegtables and fruits. 13. The charge nurse observes that a demographic screen has been left open on a hallway computer by a nurse who is responding to a call light because the unlicensed assistive personnel (UAP) is involved in a personal phone call. Which action should the charge nurse take first? • Page the unit manager to address the situation. • Close the demographic screen on the computer. Correct • Instruct the UAP to end the phone call immediately. • Send a UAP into the client's room to relieve the nurse. The greatest priority is for the charge nurse to close the computer screen (B), because health information stored in computerized systems is considered to be Protected Health Information (PHI) TestBankWorld.org

under HIPAA (Health Insurance Portability and Accountability Act). (A, C, and D) may be indicated, but are of less priority than (B). Category: Fundamentals 14. A female client informs the nurse that she uses herbal therapies to supplement her diet and manage common ailments. What information should the nurse offer the client about general use of herbal supplements? • • • •

Most herbs are toxic or carcinogenic and should be used only when proven effective. There is no evidence that herbs are safe or effective as compared to conventional supplements in maintaining health. Herbs should be obtained from manufacturers with a history of quality control of their supplements. Correct Herbal therapies may mask the symptoms of serious disease, so frequent medical evaluation is required during use.

The current availability of many herbal supplements lacks federal regulation, research, control and standardization in the manufacture of its purity and dose. Manufacturers that provide evidence of quality control (C), such as labeling that contains scientific generic name, name and address of the manufacturer, batch or lot number, date of manufacture, and expiration date, is the best information to provide. (A, B, and D) are misleading. 15. A high school senior is complaining of a persistent cough and admits to smoking 10 to 15 cigarettes daily for the past year. He is convinced that he is hopelessly addicted to tobacco since he tried unsuccessfully to quit smoking last week. Which intervention is best for the nurse to implement? • • • •

Encourage the student to associate with non-smokers only while attempting to stop smoking. Correct Tell the student that he is still young and should continue to try various smoking cessation methods. Describe cigarette smoking as a habit that requires a strong will to overcome its addictiveness. Provide the student with the latest research data describing the long-term effects of tobacco use.

It is difficult to cease smoking when surrounded by those who smoke, and adolescents are particularly influenced by peers, so (A) is the most important intervention for the nurse to implement. (B) is not likely to be helpful and offers no concrete suggestions for smoking cessation. (C) is condescending. Risks associated with smoking must already be known to this adolescent who is already attempting to stop the habit (D). Category: Fundamentals 16. When making the bed of a client who needs a bed cradle, which action should the nurse include? • • • •

Teach the client to call for help before getting out of bed. Keep both the upper and lower side rails in a raised position. Keep the bed in the lowest position while changing the sheets. Drape the top sheet and covers loosely over the bed cradle. Correct

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A bed cradle is used to keep the top bedclothes off the client, so the nurse should drape the top sheet and covers loosely over the cradle (D). A client using a bed cradle may still be able to ambulate independently (A) and does not require raised side rails (B). (C) causes the nurse to use poor body mechanics. 17. A male client with acquired immunodeficiency syndrome (AIDS) develops cryptococcal meningitis and tells the nurse he does not want to be resuscitated if his breathing stops. What action should the nurse implement? • • • •

Document the client's request in the medical record. Ask the client if this decision has been discussed with his healthcare provider. Correct Inform the client that a written, notarized advance directive, is required to withhold resuscitation efforts. Advise the client to designate a person to make healthcare decisions when the client is unable to do so.

Advance directives are written statements of a person's wishes regarding medical care, and verbal directives may be given to a healthcare provider with specific instructions in the presence of two witnesses. To obtain this prescription, the client should discuss his choice with the healthcare provider (B). (A) is insufficient to implement the client's request without legal consequences. Although (C and D) provide legal protection of the client's wishes, the present request needs additional action. 18. A client is admitted to the hospital with intractable pain. What instruction should the nurse provide the unlicensed assistive personnel (UAP) who is preparing to assist this client with a bed bath? • • • •

Take measures to promote as much comfort as possible. Correct Report any signs of drug addiction to the nurse immediately. Wait until the client's pain is gone before assisting with personal care. This client's pain will be difficult to manage, since the cause is unknown.

Intractable pain is highly resistant to pain relief measures, so it is important to promote comfort (A) during all activities. A client with intractable pain may develop drug tolerance and dependence, but (B) is inappropriate for a UAP. Since intractable pain is resistant to relief measures, (C) may not be possible. Psychogenic pain (D) is a painful sensation that is perceived but has no known cause. 19. An older client who is able to stand but not to ambulate receives a prescription to be mobilized into a chair as tolerated during each day. What is the best action for the nurse to implement when assisting the client from the bed to the chair? • • • •

Use a mechanical lift to transfer from the bed to a chair. Place a roller board under the client who is sitting on the side of the bed and slide the client to the chair. Lift the client out of bed to the chair with another staff member using a coordinated effort on the count of three. Place a transfer belt around the client, assist to stand, and pivot to a chair that is placed at a right angle to the bed. Correct TestBankWorld.org

A client who can stand can safely be assisted to pivot and transfer with the use of a transfer belt (D). A mechanical lift (A) is usually used for a client who is obese, unable to be weight-bearing, and who is unable to assist. Roller boards (B) placed under a sheet are used to facilitate the transfer of a recumbent client who is being transferred to and from a stretcher. Lifting a client (C) out of bed places the client and nurses at risk for injury and should only be implemented by skilled lift teams. 20. A male client has a nursing diagnosis of "spiritual distress." What intervention is best for the nurse to implement when caring for this client? • • • •

Use distraction techniques during times of spiritual stress and crisis. Reassure the client that his faith will be regained with time and support. Consult with the staff chaplain and ask that the chaplain visit with the client. Use reflective listening techniques when the client expresses spiritual doubts. Correct

The most beneficial nursing intervention is to use nonjudgmental reflective listening techniques, to allow the client to feel comfortable expressing his concerns (D). (A and B) are not therapeutic. The client should be consulted before implementing (C). 21. The nurse obtains a BP reading of 100/88 in the right arm of a client whose blood pressure is typically 120/60 in the same arm. What action should the nurse implement first? • • • •

Use an electronic sphygmomanometer to take the BP every 30 minutes. Retake the blood pressure in the same arm, deflating the cuff slowly. Correct Ask another nurse to recheck the blood pressure to compare results. Obtain another blood pressure cuff and retake the blood pressure.

The nurse should first retake the blood pressure in the right arm, deflating the cuff more slowly (B), because a low systolic and high diastolic blood pressure measurement is often the result of deflating the cuff too rapidly. There is no indication that the BP needs to be taken frequently (A). If the blood pressure remains low, further assessment is needed, which may include (C). If deflating the cuff slowly does not resolve the discrepancy, the nurse may then need to implement (D). Category: Fundamentals 22. A client has a nursing diagnosis of, "Spiritual distress related to a loss of hope, secondary to impending death." What intervention is best for the nurse to implement when caring for this client? • • • •

Help the client to accept the final stage of life. Assist and support the client in establishing short-term goals. Correct Encourage the client to make future plans, even if they are unrealistic. Instruct the client's family to focus on positive aspects of the client's life.

Hopefulness is necessary to sustain a meaningful existence, even close to death. The nurse should help the client set short-term goals, and recognize the achievement of immediate goals (B), such as seeing a family member, or listening to music. (A) is too vague to be a helpful intervention. (C) does not help the client deal with this nursing diagnosis. (D) might be implemented, but does not have the priority of (B).

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