Exam 3: Fundamentals and Issues of Nursing

The client has a prescription for administering an enema. After preparing the equipment and solution, the nurse assists the client into which of the following positions?

The client with right-sided pleural effusion by chest x-ray is being prepared for a thoracentesis. The nurse assists the client to which of the following positions for the procedure?

The nurse has a written prescription to discontinue an intravenous (IV) line. The nurse obtains which of the following supplies from the unit supply area for use in applying pressure to the site after removing the IV catheter?

The nurse is planning to instruct the Hispanic-American client about nutrition and dietary restrictions. When developing the plan for the instructions, the nurse is aware that this ethnic group:

An automatic external defibrillator (AED) interprets that the rhythm of a pulseless client is ventricular fibrillation. The nurse takes which of the following actions next?

A client who was receiving enteral feedings in the hospital has been started on a regular diet and is almost ready for discharge. The client will be self-administering supplemental tube feedings between meals for a short time after discharge. When the client expresses concern about his or her ability to perform this procedure at home, the nurse would best respond with which of the following?

The nurse has just reassessed the condition of the postoperative client who was admitted 1 hour ago to the surgical unit. The nurse monitors which of the following parameters during the next hour most carefully?

When performing a surgical dressing change of a client's abdominal dressing, the nurse notes an increase in the amount of drainage and separation of the incision line. The underlying tissue is visible to the nurse. The priority nursing action at this time is to:

A nurse is making initial rounds on the nursing unit to check the condition of assigned clients. The nurse notes that a client's intravenous (IV) site is cool, pale, and swollen, and the solution is not infusing. The nurse interprets that which of the following complications has been experienced by the client?

A nurse is undergoing annual recertification in basic life support (BLS). The BLS instructor asks the nurse to identify the most appropriate pulse point to use when determining pulselessness on an infant. The nurse undergoing recertification replies that the correct pulse point is:

The nurse has admitted a client to the clinical nursing unit following right-sided mastectomy. The nurse plans to place the right-sided arm in which of the following positions?

The client had a 1000-mL bag of 5% dextrose in 0.9% sodium chloride hung at 15:00. The nurse, making rounds at 15:45, finds the client is complaining of a pounding headache, is dyspneic with chills, is apprehensive, and has an increased pulse rate. The intravenous (IV) bag has 400 mL remaining. The nurse should take which of the following actions first?

The community health nurse is preparing to teach "personal and family preparedness for disasters" to a group of parents of school-age children. From the following list of items to be kept ready, identify the appropriate items that should be identified by the nurse. Select all that apply.

The nurse is caring for a client with a chest tube who accidentally disconnects the tube from the drainage system when trying to get out of bed. The nurse takes which immediate action?

The registered nurse (RN) hears a client calling out for help. The RN hurries down the hallway to the client's room and finds the client lying on the floor. The RN performs a thorough assessment and assists the client back to bed. The physician is notified of the incident, and the nurse completes an incident report. Which of the following would the RN document on the incident report?

The nurse is preparing a continuous intravenous (IV) infusion at the medication cart. As the nurse prepares to attach the distal end of the IV tubing to a needleless device, the tubing drops and hits the top of the medication cart. Which of the following is the appropriate action by the nurse?

Ampicillin sodium, 250 mg in 50 mL of normal saline, is being administered over a period of 30 minutes. The drop factor is 10 drops/mL. The nurse determines that the infusion is running at the prescribed rate if the infusion is delivering how many drops per minute? (Enter the answer in the space provided.)

The nurse employed in the ambulatory care department hears a client in the waiting room call out, "Help, fire!" The nurse rushes to the waiting room and finds the wastebasket on fire. Which action should the nurse take first?

The client has had surgery to repair a fractured left-sided hip. The nurse will use which of the following important items when repositioning the client from side to side in bed?

The nurse hears in intershift report that a client receiving parenteral nutrition (PN) at 100 mL/hr has bilateral crackles and 1+ pedal edema. When the nurse obtains a daily weight, the nurse notes that the client has gained 4 lb in 2 days. Which of the following nursing actions should the nurse take first?