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Exam 7 2018, questions and answers Fundamentals in clinical techniques (Rasmussen College). Answers and Rationale

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lOMoAR cPSD| 784381
lOMoAR cPSD| 784381
Exam 7 2018, questions and answers
Fundamentals in clinical techniques (Rasmussen College)
RN Fundamentals Online Practice
A nurse is caring for a client who requires a 24-hr urine collection. Which of the
following statements by the client indicates an understanding of the teaching?
A. "I had a bowel movement, but I was able to save the urine."
B. "I have a specimen in the bathroom from about 30 minutes ago."
C. "I flushed what I urinated at 7:00 a.m. and have save all urine since."
D. "I drink a lot, so I will fill up the bottle and complete the test quickly."
Answers available at https://bit.ly/358ttz5
A nurse is assessing a client who has been on bed rest for the past month. Which of the
following findings should the nurse identify as an indication that the client has developed
thrombophlebitis?
A. Bladder distention
B. Decreased blood pressure
C. Calf swelling
D. Diminished bowel sounds
C. Calf swelling
Answers available at https://bit.ly/358ttz5
A nurse manager is overseeing the care on a unit. Which of the following situations should
the nurse manager identify as a violation of HIPAA guidelines?
A. A nurse who is caring for a client reviews the client's medical chart with the nursing student
who is working with the nurse
B. A nurse asks a nurse from another unit to assist with her documentation
C. A nurse who is caring for a client returns a call to the client's durable power of attorney for
health care designee to discuss the client's care
D. A nurse discusses a client's status with the physical therapist that is caring for the client at the
lOMoAR cPSD| 784381
lOMoAR cPSD| 784381
client's bedside
A nurse is caring for a client who requires bed rest and has a prescription for antiembolic
stockings. Which of the following actions should the nurse take?
A. Apply the stockings so the creases are on the side of the leg
B. Apply the stockings while the client's legs are in a dependent position
C. Remove the stockings at least once per shift
D. Remove the stockings while the client is sitting in a reclining chair
E. Answers available at https://bit.ly/358ttz5
A nurse is administering IV fluid to an older adult client. The nurse should perform which
priority assessment to monitor for adverse effects?
A. Auscultate lung sounds
B. Measure urine output
C. Monitor blood pressure readings
C. Monitor serum electrolyte levels
A. Auscultate lung sounds
A nurse is assessing a client's readiness to learn about insulin administration. Which of the
following statements should the nurse identify as an indication that the client is ready to
learn?
A. "I can concentrate best in the morning."
B. "It is difficult to read the instructions because my glasses are at home."
C. "I'm wondering why I need to learn this."
D. "You will have to talk to my wife about this."
A nurse is performing a Romberg's test during the physical assessment of a client. Which of
the following techniques should the nurse use?
A. Touch the face with a cotton ball
lOMoAR cPSD| 784381
lOMoAR cPSD| 784381
B. Apply the vibrating tuning fork to the client's forehead
C. Have the client stand with her arms at her side and her feet together
D. Perform direct percussion over the area of the kidneys
E. Answers available at https://bit.ly/358ttz5
A nurse is planning an education session for an older adult client who has just learned
that she has type 2 diabetes mellitus. Which of the following strategies should the nurse
plan to use with this client?
A. Allow extra time for the client to respond to questions
B. Expect the client to have difficulty understanding the information
C. Avoid references to the client's past experiences
D. Keep the learning session in private and one-on-one
A nurse is teaching an older adult client who is at risk for osteoporosis about beginning a
program of regular physical activity. Which of the following types of activity should the
nurse recommend?
A. Walking briskly
B. Riding a bicycle
C. Performing isometric exercises
D. Engaging in high-impact aerobics
E. Answers available at https://bit.ly/358ttz5
A nurse is assessing an adult client who has been immobile for the past 3 weeks. The nurse
should identify that which of the following findings requires further intervention?
A. Erythema on pressure points
B. Lower-extremity pulse strength 2+
C. Fluid intake of 3,000 mL of fluid per day
D. A bowel movement every other day
A nurse is preparing to administer 0.5 mL of oral single-dose liquid medication to a
lOMoAR cPSD| 784381
lOMoAR cPSD| 784381
client. Which of the following actions should the nurse take?
A. Gently shake the container of medication prior to administration
B. Transfer the medication to a medicine cup
C. Place the client in a semi-Fowler's position prior to medication administration
D. Verify the dosage by measuring the liquid before administration
A nurse is responding to a call light and finds a client lying on the bathroom floor. Which of
the following actions should the nurse take first?
A. Check the client for injuries
B. Move hazardous objects away from the client
C. Notify the provider
D. Ask the client to describe how she felt prior to the fall
A nurse is caring for a client who is expressing anger over his diagnosis of colorectal cancer.
Which of the following actions should the nurse take?
Answers available at https://bit.ly/358ttz5
A. Discuss the risk factors for colon cancer
B. Focus teaching on what the client will need to do in the future to manage his illness
C. Provide the client with written information about the phases of loss and grief
D. Reassure the client that this is an expected response to grief
A nurse in a clinic is caring for a middle adult client who states, "The doctor says that,
since I am at an average risk for colon cancer, I should have a routine screening. What
does that involve?" Which of the following responses should the nurse make?
A. "I'll get a blood sample from you and send it for a screening test."
B. "Beginning at age 600, you should have a colonoscopy."
C. "You should have a fecal occult blood test every year."
D. "The recommendation is to have a sigmoidoscopy every 10 years."
lOMoAR cPSD| 784381
lOMoAR cPSD| 784381
A nurse manager is preparing to review medication documentation with a group of newly
licensed nurses. Which of the following statement should the nurse manager plan to include
in the teaching?
A. "Use the complete name of the medication magnesium sulfate."
B. "Delete the space between the numerical dose and the unit of measure."
C. "Write the letter U when noting the dosage of insulin.:
D. "Use the abbreviation SC when indicting an injection."
A nurse is caring for a client who has tuberculosis. Which of the following actions should
the nurse take? (Select all that apply.)
Answers available at https://bit.ly/358ttz5
A. Place the client in a room with negative-pressure airflow
B. Wear gloves when assisting the client with oral care
C. Limit each visitor to 2 hr increments
D. Wear a surgical mask when providing client care
E. Use antimicrobial sanitizer for hand hygiene
A charge nurse is discussing the responsibility of nurses caring for clients who have a
Clostridium difficile infection. Which of the following information should the nurse include
in the teaching?
A. Assign the client to a room with a negative air-flow system
B. Use alcohol-based hand sanitizer when leaving the client's room
C. Clean contaminated surface in the client's room with a phenol solution
D. Have family members wear a gown and gloves when visiting
A nurse in a surgical suite notes documentation on a client's medical record that he has a
latex allergy. In preparation for the client's medical record that he has a latex allergy. In
preparation for the client's procedure, which of the following precautions should the nurse
take?
lOMoAR cPSD| 784381
lOMoAR cPSD| 784381
A. Ensure sterilization of non-disposable items with ethylene oxide
B. Wrap monitoring cords with stockinette and tape them in case
Answers available at https://bit.ly/358ttz5
lOMoAR cPSD| 784381
lOMoAR cPSD| 784381
C. Cleanse latex ports on IV tubing with chlorhexidine before injecting medication
D. Wear hypoallergenic later gloves that contain powder
A nurse is caring for a client who is reporting difficulty falling asleep. Which of the
following measures should the nurse recommend?
A. Drink a cup of hot cocoa before bedtime
B. Exercise 1 hr before going to bed
C. Use progressive relaxation techniques at bedtime
D. Reflect on the day's activities before going to bed
A nurse is caring for a client who has a prescription for 5 units of regular insulin and 10
units of NPH insulin to mix together and administer subcutaneously. Determine the
correct order of steps for this procedure.
A nurse is reviewing practice guidelines with a group of newly licensed nurses. Which of the
following interventions should the nurse include that is within the RN scope of practice?
A. Insert an implanted port
B. Close a laceration with sutures
C. Place an endotracheal tube
D. Initiate an enteral feeding through a gastrostomy tube
A nurse is caring for a client who requires an NG tube for stomach decompression. Which
of the following actions should the nurse take when inserting the NG tube?
A. Position the client with the head of the bed elevated to 30 degrees prior to insertion of the NG
tube
B. Remove the NG tube if the client begins to gag or choke
C. Apply suction to the NG tube prior to insertion
lOMoAR cPSD| 784381
lOMoAR cPSD| 784381
D. Have the client take sips of water to promote insertion of the NG tube into the esophagus
A nurse is assessing an older adult client's risk for falls. Which of the following assessments
should the nurse use to identify the client's safety needs? (Select all that apply.)
A. Lacrimal apparatus
B. Pupil clarity
C. Appearance of bulbar conjunctivae
D. Visual fields
E. Visual acuity
A nurse is evaluating a client's use of a cane. Which of the following actions should the
nurse identify as an indication of correct use?
A. The top of the cane is parallel to the client's waist
B. When walking, the client moves the cane 46cm (18 in) forward
C. The client holds the cane on the stronger side of her body.
D. The client moves her stronger limb forward with the cane
A nurse is admitting a client who has varicella. Which of the following types of
transmission precautions should the nurse initiate?
A. Airborne
B. Droplet
C. Contact
D. Protective environment
A nurse is preparing to administer multiple medications to a client who has an enteral
feeding tube. Which of the following actions should the nurse plan to take?
A. Dissolve each medication in 5 mL of sterile water
B. Draw up medications together in the same syringe
C. Push the syringe plunger gently when feeling resistance
lOMoAR cPSD| 784381
lOMoAR cPSD| 784381
D. Flush the tube with 15 mL of sterile water
A nurse is caring for a client who has a prescription for wound irrigation. Which of the
following actions should the nurse take?
A. Wear sterile gloves when removing the old dressing
B. Warm the irrigation solution to 40.5 degrees Celsius (105 degrees Fahrenheit)
C. Cleanse the wound from the center outward
D. Use a 20 mL syringe to irrigate the wound
A nurse is providing care to four clients. Which of the following situations requires the
nurse to complete an incident report?
A. A nurse tied a client's restraint straps to the moveable part of the bed frame
B. An assistive personnel placed a surgical mask on a client who has tuberculosis before
transporting her to radiology
C. A nurse administers a medication to a client 30 minutes before the dose is due
D. A client who has an IV infusion pump receives an additional 250 mL of IV fluid
A nurse is caring for a client receiving fluid through a peripheral IV catheter. Which of the
following findings at the IV site should the nurse identify as infiltration?
A. Purulent exudate
B. Warmth
C. Skin blanching
D. Bleeding
A nurse is preparing a change-of-shit report. Which of the following tools or documents
should the nurse use to communicate continuity of care?
A. Critical pathway
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lOMoAR cPSD| 784381
B. Situation, background, assessment, and recommendation (SBAR)
C. Transfer report
D. Medication administration record (MAR)
A nurse is admitting a client who has an abdominal wound with a large amount of purulent
drainage. Which of the following types of transmission precautions should the nurse
indicate?
A. Protective environment
B. Airborne precautions
C. Droplet precaution
D. Contact precautions
A nurse is caring for a client who is having difficulty breathing. The client is lying in bed
with a nasal cannula delivering oxygen. Which of the following interventions should the
nurse take first?
A. Suction the client's airway
B. Administer a bronchodilator
C.Increase the humidity in the client's room
D. Assist the client to an upright position
A nurse is reviewing a client's fluid and electrolyte status which of the following findings
should the nurse report to the provider?
A. BUN 15 mg/dL
B. Creatinine 0.8 mg/dL
C. Sodium 143 mEq/L
D. Potassium 5.4 mEq/L
A nurse is lifting a bedside cabinet to move it closer to a client who is sitting in a chair. To
prevent self- injury, which of the following actions should the nurse take when lifting the
lOMoAR cPSD| 784381
lOMoAR cPSD| 784381
object?
A. Bend at the waist
B. Keep his feet close together
C. Use his back muscles for lifting
D. Stand close to the cabinet when lifting
A nurse is reviewing a client's medication prescription, which reads, "digoxin 0.25 by
mouth every day." Which of the following components of the prescription should the
nurse question?
A. The medication
B. The route
C. The dose
D. The frequency
A nurse is caring for a client who has had his diet prescription changed to a mechanical
soft diet. Which of the following food items should the nurse remove from the client's
breakfast tray?
A. Tomato juice
B. Banana slices
C. Pancakes
D. Fried egg
A nurse is caring for a client who has terminal liver cancer. Which of the following
statements should the nurse identify as an indication that the client is experiencing spiritual
distress?
A. "What could I have done to deserve this illness?"
lOMoAR cPSD| 784381
lOMoAR cPSD| 784381
B. "I blame medical science for not curing me."
C. "Where is my daughter at a time like this?"
D. "Will I ever begin to feel in charge of my life again?"
A nurse is caring for a client who is refusing a blood transfusion for religious reasons.
The client's partner wants the client to have the blood transfusion. Which of the
following actions should the nurse take?
A. Ask the client to consider a direct donation
B. Withhold the blood transfusion
C. Request a consultation with the ethics
committee D.. Ask the client's family to
intervene
A nurse is reviewing protocol in preparation for suctioning secretions from a client who has
a new tracheostomy. Which of the following actions should the nurse plan to take?
A. Use a resuscitation bag with 80% oxygen prior to the procedure
B. Select a suction catheter that is half the size of the lumen
C. Place the end of the suction catheter in water-soluble lubricant
D. Adjust the wall suction apparatus to a pressure of 170 mmHg
A nurse is caring for a client who has limited mobility in his lower extremities. Which of the
following actions should the nurse take to prevent skin breakdown?
A. Place the client in high-Fowler's position
B. Increase the client's intake of carbohydrates
C. Massage reddened areas with unscented lotion
D. Have the client use a trapeze bar when changing position
lOMoAR cPSD| 784381
lOMoAR cPSD| 784381
A nurse is talking with the partner of an older adult male client who has dementia. The
client's partner expresses frustration about finding time to manage household
responsibilities while caring for his partner. The nurse should identify that he is going
through which of the following types of role- performance stress?
A. Role ambiguity
B. Sick role
C. Role overload
D. Role conflict
C. Role overload
A nurse in a long-term care facility is planning to perform hygiene care for a new
resident. Which of the following assessment questions is the nurse's priority before
beginning this procedure?
A. "When do you usually bathe, in the morning or in the evening?"
B. "Do you prefer a bath or a shower?"
C. "At what temperature do you prefer your bath water?"
D. "Are you able to help with your hygiene care?"
A nurse is caring for a client who has herpes zoster and asks the nurse about the use of
complementary and alternative therapies for pain control. The nurse should inform the
client that his condition is a contraindication for which of the following therapies?
A. Biofeedback
B. Aloe
C. Feverfew
D. Acupuncture
lOMoAR cPSD| 784381
lOMoAR cPSD| 784381
A nurse is giving discharge instructions to a client who will require oxygen therapy at home.
Which of the following statements should the nurse identify as an indication that the client
understands how to manage this therapy at home?
A. "I'll make sure that, when my friend comes by, she smokes at least 6 feet away from my
oxygen.
B. "I'll use a woolen blanket if I get chilly while I'm using my oxygen.
C. "I'll check the wires and cables on my TV to make sure they are in good working order.
D. "I'll lay my oxygen tank down on the floor when the grandchildren visit so they don't knock it
over.
A nurse is preparing to administer an injection of an opioid medication to a client. The
nurse draws out 1 mL of the medication from a 2 mL vial. Which of the following actions
should the nurse take?
A. Ask another nurse to observe the medication wastage
B. Notify the pharmacy when wasting the medication
C. Lock the remaining medication in the controlled substances cabinet
D. Dispose of the vial with the remaining medication in a sharps container
A nurse is caring for a client who is terminally ill. Which of the following statements should
the nurse identify as an indication that the client's family member is coping effectively with
the situation?
A. "We are not worried. We still have hope that everything will be okay."
B. "This is a difficult time, but we are helping each other through this."
C. "After he comes home, we can plan our family reunion."
D. "We do not need to talk about funeral arrangements at this time."
A nurse is planning care to improve self-feeding for a client who has vision loss. Which of
the following interventions should the nurse include in the plan of care?
lOMoAR cPSD| 784381
lOMoAR cPSD| 784381
A. Tell the client which food should should eat first.
B. Provide small-handle utensils for the client.
C. Thicken liquids on the client's tray
D. Use a clock pattern to describe food on the client's plate
A nurse is preparing to transfer a client who has right-sided weakness from the bed to a
chair. In what order should the nurse take the following actions to assist the client?
A nurse is caring for a client who reports pain. When documenting the quality of the
client's pain on an initial pain assessment, the nurse should record which of the following
client statements?
A. "I'm having mild pain."
B. "The pain is like a dull ache in my stomach."
C. "I notice that the pain gets worse after I eat."
D. "The pain makes me feel nauseous."
A nurse is caring for a client who asks about the purpose of advance directives. Which of the
following statements should the nurse make?
A. "They allow the court to overrule an adult client's refusal of medical treatment."
B. "They indicate the form of treatment the client is willing to accept in the event of serious
illness."
C. "They permit a client to withhold medical information from health care personnel."
D. "They allow health care personnel in the emergency department to stabilize a client's
condition."
A nurse is completing an admission assessment for a client who reports vomiting and
diarrhea for the past 3 days. Which of the following assessment findings should the nurse
expect?
A. Neck vein distention
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lOMoAR cPSD| 784381
B. Urine specific gravity 1.010
C. Rapid heart rate
D. Blood pressure 144/82 mmHg
A nurse is caring for a client who is postoperative and refuses to use an incentive spirometer
following major abdominal surgery. Which of the following is the nurse's priority action?
A. Request that a respiratory therapist discuss the technique for incentive spirometry
B. Determine the reasons why the client is refusing to use the incentive spirometer
C. Document the client's refusal to participate in health restorative activities
D. Administer a pain medication to the client
A nurse is caring for a client who has an NG tube and is receiving intermittent feedings
through an open system. Which of the following actions should the nurse take first?
A. Rinse the feeding bag with water between feedings
B. Tell the client to keep the head of the bed elevated at least 30 degrees
C. Make sure the enteral formula is at room temperature
D. Wipe the top of the formula can with alcohol
A nurse is administering an otic medication to an older adult client. Which of the following
actions should the nurse take to ensure that the medication reaches the inner ear?
A. Press gently on the tragus of the client's ear
B. Pack a small piece of cotton deep into the ear canal
C. Move the client's auricle down and back toward her head
D. Tilt the client's head back for 5 minutes
A nurse is using an open irrigation technique to irrigate a client's indwelling urinary
catheter. Which of the following actions should the nurse take?
A. Place the client in a side-lying position
B. Instill 15 mL of irrigation fluid into the catheter with each flush
lOMoAR cPSD| 784381
lOMoAR cPSD| 784381
C. Subtract the amount of irrigant used from the client's urine output
D. Perform the irrigation using a 20 mL syringe
A nurse is planning to insert a peripheral IV catheter for an older adult client. Which of the
following actions should the nurse plan to take?
A. Insert the catheter at a 45 degree angle
B. Place the client's arm in a dependent position
C. Shave excess hair from the insertion site
D. Initiate IV therapy in the veins of the hand
A nurse is assisting a client who is postoperative with the use of an incentive spirometer.
Into which of the following positions should the nurse place the client?
A. Side-lying
B. Supine
C. Semi-Fowler's
D. Trendelenburg
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