Foundations of care

Question 1

a Spanish speaking client arrives at the triage desk in the emergency department and states to the nurse that an interpreter is needed. which is the best action for the nurse to take?

Answer 1

page an interpreter from the hospitals interpreter from the hospitals interpreter services.

Question 2

the nurse is performing a neurological assessment on a client and notes a positive Romberg’s test. the nurse base this determination based on which observation?

Answer 2

a significant sway when the client stands erect with feet together , arms at the side, and the eyes closed.

Question 3

the nurse notes documentation that a client is exhibiting Cheyne-stokes respirations. on assessment of the client, the nurse should expect to note this finding?

Answer 3

rhythmic respirations with periods of apnea

Question 4

a client diagnosed with conductive hearing loss asks the nurse to explain the cause of the hearing problem. the nurse plans to explain to the client that this condition is caused by which problem?

Answer 4

a physical obstruction to the transmission of sound waves.

Question 5

while performing a cardiac assessment on a client with an incompetent heart valve, the nurse auscultates a murmur. the nurse documents the finding and describes the sound as which?

Answer 5

a blowing or swooshing noise

Question 6

the nurse is testing the extraocular movement in a client to assess for muscle weakness in the eyes. the nurse should implement which assessment technique to assess for muscle weakness in the eye?

Answer 6

Test the 6 cardinal positions of gaze.

Question 7

the nurse is instructing a client how to perform a testicular self-examination (TSE). The nurse should explain that which is the best time to perform this exam?

Answer 7

after a shower or bath

Question 8

the nurse is assessing a client suspected of having meningitis ( an inflammation (swelling) of the protective membranes covering the brain and spinal cord) for meningeal irritation and elicits a positive Brudzinsis sign. which finding did the nurse observe?

Answer 8

the client passively flexes the hip and knee in response to neck flexion and reports pain in the vertebral column.

Question 9

a client with a diagnosis of asthma is admitted to the hospital with respiratory distress. which type of adventitious lung sounds should the nurse expect to hear when performing a respiratory assessment on this client?

Answer 9

wheezing

Question 10

the clinic nurse prepares to perform a focused assessment on a client who is complaining of symptoms of a cold, a cough, and lung, congestion. which should the nurse include for this type of assessment? select all that apply.

Answer 10

auscultating lung sounds. obtaining the clients temperature . obtaining information about the clients respirations.

Question 11

the nurse is preparing to initiate an intravenous (IV) line containing a high dose of potassium chloride using an Iv infusion pump. while preparing to plug the pump cord into the wall, the nurse finds that no receptacle is available in the wall socket. the nurse should take which action?

Answer 11

contact the electrical maintenance department for assistance.

Question 12

the nurse obtains a prescription from a primary health care provider to restrain a client and instructs an assistive personnel (AP) to apply the safety device to the client. which observation of unsafe application of the safety device would indicate that further instruction is required for the AP?

Answer 12

safely securing the safety device straps to the side rails.

Question 13

the community health nurse is providing a teaching session about anthrax to members of the community and ask the participants about the methods of transmission. which answer by the participants would indicate that teaching was effective? select all that apply.

Answer 13

inhalation of bacterial spores.
through a cut or abrasion in the skin.
ingestion of contaminated undercooked meat.

Question 14

the nurse is giving report to an assistive personnel (AP) who will be caring for a client in hand restraints (safety devices). how frequently should the nurse instruct the AP to check the tightness of the restrained hands?

Answer 14

every 30 minutes.

Question 15

the nurse is reviewing a plan of care for a client with an internal radiation implant. which intervention, if noted in the plan, indicates the need for revision of the plan?

Answer 15

placing the client in a semiprivate room at the end of the hallway.

Question 16

contact precautions are initiated for a client with a health care associated (nosocomial) infection caused by methicillin-resistant staphylococcus aureus (MRSA). The nurse prepares to provide colostomy care and should obtain which protective items to perform this procedure?

Answer 16

gloves, gown, goggles, and a mask or face shield

Question 17

the nurse enters a clients room and finds that the waste basket is on fire. the nurse immediately assists the client out of the room. what is the next nursing action?

Answer 17

activate the fire alarm

Question 18

a mother calls a neighbor who is a nurse and tells the nurse that her 3 year old child has just ingested liquid furniture polish. the nurse would direct the mother to take which immediate action?

Answer 18

call the poison control center.

Question 19

the emergency department (ED) nurse receives a telephone call and is informed that a tornado has hit a local residential area and that numerous casualties have occurred. the victims will brought to the ED. The nurse should take which initial action?

Answer 19

Activate the emergency response plan specific to the facility.

Question 20

the nurse is caring for a client with meningitis (transmitted by droplet infection) and implements which transmission-based precautions for this client?

Answer 20

private room or cohort client

Question 21

the nurse working in the emergency department (ED) is assessing a client who recently returned from Nigeria and presented complaining of a fever at home, fatigue, muscle pain, and abdominal pain. which action should the nurse take next?

Answer 21

isolate the client in a private room.