Fundamentals Of Nursing

1. The nurse assesses a postoperative client who has a rapid, weak pulse; urine output of less than 30 mL/h; and decreased blood pressure. The client's skin is cool and clammy. What complication should the nurse suspect?

Thrombophlebitis

Hypovolemic shock

Pneumonia

Wound dehiscence

The symptoms describe decreased cardiac output and not any of the other listed complications.

Explanation

The symptoms describe decreased cardiac output and not any of the other listed complications.

2. The nurse positions the client sitting upright during palpation of which area?

Abdomen

Genitals

Breast

Head and neck

The client should sit for examination of the head and neck. For palpation of the abdomen (option A), genitals (option B), and breast (option C), the client should be supine.

Explanation

The client should sit for examination of the head and neck. For palpation of the abdomen (option A), genitals (option B), and breast (option C), the client should be supine.

3. Which charting entry would be the most defensible in court?

Client fell out of bed

Client drunk on admission

Large bruise on left thigh

Notified Dr. Jones of BP of 90/40

Option D is the “best” answer although it could be more complete by adding the response of the primary care provider. Option A is too vague because it is not clear if the nurse found the client or was present when the client fell. Also, there is no need to write the word client because it is the client’s chart. Option B is judgmental, revealing a negative attitude toward the person. It would be better to describe specific signs and symptoms such as staggering, slurred speech, and smell of alcohol on breath. Option C is too general and can be more specific by charting “2 cm × 3 cm purplish bruise on mid-inner thigh along with color.”

Explanation

Option D is the “best” answer although it could be more complete by adding the response of the primary care provider. Option A is too vague because it is not clear if the nurse found the client or was present when the client fell. Also, there is no need to write the word client because it is the client’s chart. Option B is judgmental, revealing a negative attitude toward the person. It would be better to describe specific signs and symptoms such as staggering, slurred speech, and smell of alcohol on breath. Option C is too general and can be more specific by charting “2 cm × 3 cm purplish bruise on mid-inner thigh along with color.”

4. Proper administration of an otic medication to a 2-year-old client includes which of the following?

Pull the ear straight back.

Pull the ear down and back.

Pull the ear up and back.

Pull the ear straight upward.

To straighten the ear canal in children less than 3 years of age, the ear must be pulled down and back. In individuals over 3 years of age, the ear is pulled up and back.

Explanation

To straighten the ear canal in children less than 3 years of age, the ear must be pulled down and back. In individuals over 3 years of age, the ear is pulled up and back.

5. The nurse practitioner requests a laboratory blood test to determine how well a client has controlled her diabetes during the past 3 months. Which blood test will provide this information?

Fasting blood glucose

Capillary blood specimen

Glycosylated hemoglobin

GGT (gamma-glutamyl transferase)

A glycosylated hemoglobin will indicate the glucose levels for a period of time, which is indicated by the nurse practitioner. Options A and B will provide information about the current blood glucose, not the past history. Option D is used to assess for liver disease.

Explanation

A glycosylated hemoglobin will indicate the glucose levels for a period of time, which is indicated by the nurse practitioner. Options A and B will provide information about the current blood glucose, not the past history. Option D is used to assess for liver disease.

6. The client is most likely to require the greatest amount of analgesia for pain during which period?

Immediately after surgery

4 hours after surgery

12 to 36 hours after surgery

48 to 60 hours after surgery

Options A and B are incorrect because the client is still recovering from the anesthesia used during surgery. Option D is incorrect because pain usually decreases after the second or third post-operative day.

Explanation

Options A and B are incorrect because the client is still recovering from the anesthesia used during surgery. Option D is incorrect because pain usually decreases after the second or third post-operative day.

7. Which statement best reflects the nurse's assessment of the fifth vital sign?

"Do you have any complaints?"

"Are you experiencing any discomfort right now?"

"Is there anything I can do for you now?"

"Do you have any complaints of pain?"

The words pain or complain may have emotional or sociocultural meanings (options A and D). It is better to ask clients if they are having any discomfort—they can then elaborate in their own words. Option C is too general and expects clients to report their pain without being asked.

Explanation

The words pain or complain may have emotional or sociocultural meanings (options A and D). It is better to ask clients if they are having any discomfort—they can then elaborate in their own words. Option C is too general and expects clients to report their pain without being asked.

8. A client is admitted to the hospital for hypocalcemia. Nursing interventions relating to which system would have the highest priority?

Renal

Cardiac

Gastrointestinal

Neuromuscular

The major clinical signs and symptoms of hypocalcemia are due to increased neuromuscular activity and not the renal, cardiac, or GI systems.

Explanation

The major clinical signs and symptoms of hypocalcemia are due to increased neuromuscular activity and not the renal, cardiac, or GI systems.

9. Which action by the nurse represents proper nasopharyngeal/ nasotracheal suction technique?

Lubricate the suction catheter with petroleum jelly before and between insertions.

Apply suction intermittently while inserting the suction catheter.

Rotate the catheter while applying suction.

Hyperoxygenate with 100% oxygen for 30 minutes before and after suctioning.

Rotating the catheter prevents pulling of tissue into the opening on the catheter tip and side. Suction catheters may only be lubricated with water or water-soluble lubricant (petroleum jelly, e.g., Vaseline, has an oil base) (option A). No suction should ever be applied while the catheter is being inserted because this can traumatize tissues (option B). The client should be hyperoxygenated for only a few minutes before and after suctioning and this is generally limited to clients who are intubated or have a tracheostomy (option D).

Explanation

Rotating the catheter prevents pulling of tissue into the opening on the catheter tip and side. Suction catheters may only be lubricated with water or water-soluble lubricant (petroleum jelly, e.g., Vaseline, has an oil base) (option A). No suction should ever be applied while the catheter is being inserted because this can traumatize tissues (option B). The client should be hyperoxygenated for only a few minutes before and after suctioning and this is generally limited to clients who are intubated or have a tracheostomy (option D).

10. Health promotion is best represented by which activity?

Administering immunizations

Giving a bath

Preventing accidents in the home

Performing diagnostic procedures

Health promotion focuses on maintaining normal status without consideration of diseases. Option A is an example of illness prevention. Option B is aesthetic (i.e., not needed for health promotion or disease prevention). Option D focuses on disease detection.

Explanation

Health promotion focuses on maintaining normal status without consideration of diseases. Option A is an example of illness prevention. Option B is aesthetic (i.e., not needed for health promotion or disease prevention). Option D focuses on disease detection.