Fundamental Exam 1

44 Questions | Total Attempts: 103

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Book Quizzes & Trivia

Exam 1, questions from the back of the book.


Questions and Answers
  • 1. 
    The client's temp at 8:00 am, using an oral thermometer is 36.1° C (97.2° F).  If the resp, pulse and bp are WNL, what would the nurse do next?
    • A. 

      Wait 15 min, retake

    • B. 

      Check what the client's temperature was the last time

    • C. 

      Retake it using a different thermometer

    • D. 

      Chart the temp, it is normal

  • 2. 
    • A. 

      A client is in shock

    • B. 

      The pulse changes with body position changes

    • C. 

      A client with an arrhythmia

    • D. 

      It is less than 24 hours since a client's surgical operation

  • 3. 
    When the nurse enter the room to enter vital signs in preparing the client for a dx test, the client is on the phone. What technique should the nurse use to determine the resp. rate?
    • A. 

      Count the resps during conversational pauses

    • B. 

      Ask the client to tend the phone call now and resume it at a later time.

    • C. 

      Wait at the client's bedside until the phone call is completed, then count resps

    • D. 

      Since there is no evidence of distress or urgency, defer the measurement

  • 4. 
    For a client with a previous blood pressure of 138/74 and pulse of 64, approx. how long should the nurse take to release the bp cuff in order to obtain an accurate reading?
    • A. 

      10-20 sec

    • B. 

      30-45 sec

    • C. 

      1-1.5 min

    • D. 

      3-3.5 min

  • 5. 
    It would be appropriate to delegate the taking of vital signs of which of the following clients to a UAP?
    • A. 

      A client being prepared for elective facial surgery with a hx of stable hypertension

    • B. 

      A client receiving a blood transfusion with a history of transfusion reactions

    • C. 

      A client recently started on a new antiarrhythmic agent

    • D. 

      A client who is admitted frequently with asthma attacks

  • 6. 
    An 85-year-old client has had  a stroke resulting in right sided facial drooping, difficulty swalling and is unable to move self or maintain position unaided. The nurse determines that which of the follow sites is appropriate for taking temp
    • A. 

      Oral, Tympanic, Rectal

    • B. 

      Rectal, Tympanic, Axillary

    • C. 

      Axillary, Typmpanic, Temporal

    • D. 

      Axillary, Temporal, Oral

  • 7. 
    The nurse reports that the client has dyspena when ambulating. The nurse is most likely assessed which of the following?
    • A. 

      Shallow respirations

    • B. 

      Wheezing

    • C. 

      Shortness of breath

    • D. 

      Coughing up blood

  • 8. 
    It is important to remove gloves and gown in the room if the client is under which of the following precautions?
    • A. 

      Standard

    • B. 

      Airborne

    • C. 

      Contact

    • D. 

      Droplet

  • 9. 
    Place the following nurse priories in correct sequence if a fire occurs in a health setting.1.  report the fire2.  extinguish the fire3.  protect the clients4.  contain the fire
    • A. 

      1,4,3,2

    • B. 

      3,1,4,2

    • C. 

      3,2,4,1

    • D. 

      2,3,4,1

  • 10. 
    • A. 

      Automobile crashes

    • B. 

      Drowning and firearms

    • C. 

      Falls

    • D. 

      Suicide and homicide

  • 11. 
    Because a hospitalized elderly female client, who ambulates with a walker, is receiving diuretics which result in frequent trips to the bathroom at night, the nurse should perform which of the following?
    • A. 

      Leave the bathroom light on

    • B. 

      Withhold the client's diuretic medication

    • C. 

      Provide bedside commode

    • D. 

      Keep the side rails up

  • 12. 
    Which NADA nursing dx is most applicable for toddlers?
    • A. 

      Risk for suffocation

    • B. 

      Risk for injury

    • C. 

      Risk for poisoning

    • D. 

      Risk for disuse syndrome

  • 13. 
    A 75-year-old client, hospitalized with cerebral vascular accident (stroke), becomes disoriented at times and tries to get out of bed, but is unable to ambulate without help. What is the most appropriate safety measure?
    • A. 

      Restrain the client in the bed

    • B. 

      Ask a family member to stay with the client

    • C. 

      Check the client every 15 min

    • D. 

      Use a bed exit safety monitoring device

  • 14. 
    A client is being admitted to the hospital because of a seizure that occurred at his home.  The client has no previous history of seizures.  In planning the client's nursing care, which of the following measures is most essential at this time of admission?1. Place a padded tongue depressor at the head of the bed2. Pad the bed with blankets3. Inform the client about importance of a medical tag4. Teach the client about epilepsy5. Test oral suction equipment
    • A. 

      2,4,5

    • B. 

      1,3

    • C. 

      3,4,5

    • D. 

      2,5

    • E. 

      2,3,4,5

  • 15. 
    Which of the following nursing interventions is the highest in priority for a client at risk for falls in a hospital setting?
    • A. 

      Keep all of the side rails up

    • B. 

      Review medications

    • C. 

      Complete the get up and go test

    • D. 

      Place the bed in the lowest position

  • 16. 
    When planning to teach health care topics to a group of male adolescents, the nurse should consider which of the following topics take priority?
    • A. 

      Sports contribute to self-esteem

    • B. 

      Sunbathing and tanning beds can be dangerous

    • C. 

      Guns are the most frequently used weapon in adolescent suicide

    • D. 

      A river's education course is mandatory for safety

  • 17. 
    A client can bathe independently except for the back and feet, walk to and from the bathroom and dress if the clothing is provided.  What is the most appropriate functional level for this client?
    • A. 

      Totally dependent (+4)

    • B. 

      Moderately dependent (+3)

    • C. 

      Semidependent (+2)

    • D. 

      Independent (0)

  • 18. 
    A client with diabetes has very dry skin on her feet and lower extremities. To maintain intact skin the nurse teaches which of the following?
    • A. 

      Soak feet frequently

    • B. 

      Use of non-perfumed lotion

    • C. 

      Apply foot powder

    • D. 

      Avoid knee high elastic stockings

  • 19. 
    The client wears an in-the-ear hearing aid and because of arthritis needs someone to insert the hearing aid.  THe nurse teachers the UAP to do which of the following actions before inserting the client's hearing aid?
    • A. 

      Turn the hearing aid off

    • B. 

      Soak the hearing aid in soapy solution to clean it

    • C. 

      Turn the volume all the way up

    • D. 

      Remove the batteries

  • 20. 
    • A. 

      An open bed in low position

    • B. 

      An occupied bed in low position

    • C. 

      A closed bed in high position

    • D. 

      A surgical bed in high position

  • 21. 
    The nurse observed the UAP performing perineal care for a client. WHich of the following actions indicates that further teaching is required?
    • A. 

      Used a clean potion of the wash cloth for each stroke

    • B. 

      Wiped from the pubis to the rectum

    • C. 

      Used clean gloves

    • D. 

      Did not retract foreskin

  • 22. 
    The nurse is discussing foot care with a client who was recently dx with diabetes.  Which of the following statements indicates a need for further teaching?
    • A. 

      I am going to use a mirror to check my feet

    • B. 

      I enjoy walking barefoot around the house

    • C. 

      I will file my nails

    • D. 

      I will increase the time that I wear new shoes each day

  • 23. 
    The client is experiencing labored, shortness of breath has a respiratory rate of 28.  The bed is currently in the flat position.  The best nursing intervention includes putting the bed in which of the following positions?
    • A. 

      Fowler's

    • B. 

      Semi-Folwers

    • C. 

      Trendelenburg

    • D. 

      Reverse Trendelenburg

  • 24. 
    • A. 

      Imbalanced nutrition: Less than body requirements

    • B. 

      Imbalanced nutrition: more than body requirements

    • C. 

      Risk for imbalanced nutrition

    • D. 

      Deficient knowledge

  • 25. 
    An adult reports eating, on average, the following each day: 3 cups dairy, 2 cups fruit, 5 ounces grain, and 5 ounces meat. The nurse counsel would be:
    • A. 

      Maintain the diet; servings are adequate

    • B. 

      Increase the number of servings dairy

    • C. 

      Decrease the number of servings of vegetables

    • D. 

      Increase the number of servings of grains