FUNDAMENTALS
The LPN/LVN is being evaluated by the charge nurse. Which finding about the LPN’s/LVN’s appearance indicates the charge nurse will need to intervene?
Has professionally painted, long fingernails
Has tattoos on the shoulder that remain covered
Hair is long and pulled back
Deodorant is worn every day
Has professionally painted, long fingernails
A client who prefers vegetarian menus states that he has a greater need for carbohydrates and has not given thought to the amount of protein to consume. You would explain that the importance of eating at least the minimum daily requirements of protein is to allow the body to have:
adequate structural material for body tissues.
a limited amount of fat.
adequate calories for maintaining blood glucose.
adequate calcium for bone density.
Adequate structural material for body tissues.
A patient has edema of the lower extremities. The nurse is assessing whether it is pitting and to what degree. After pressing the skin against a bony prominence for 5 seconds, the nurse identifies 2+ pitting edema because the edema disappears in:
10-15 seconds
20-25 seconds
30-35 seconds
40-45 seconds
10-15 seconds
The nurse is assisting the health-care provider during a lumbar puncture. The nurse is standing across from the health-care provider and helping the patient maintain a curled, side-lying position. The nurse accidentally places a hand on the sterile drape when shifting a grip on the patient. Which action will the nurse take?
Stop the procedure until the sterile drape is replaced.
Apologize to the health-care provider for breaking the sterile field.
Ask another nurse to take the nurse’s place at the bedside.
Explain to the health-care provider what happened to cause the breach of sterility.
Stop the procedure until the sterile drape is replaced.
3,000 mg - __g
67 mm = __ cm (Document to the tenth place)
670,000 mcg = __ g (Document to the tenth place)
3G
6.7CM
0.7G
The nurse finds a visitor lying in the hallway. The visitor states, “The floor was wet, and I fell.” The patient has no apparent injuries and refuses medical attention. The nurse fills out an incident report. Which entry by the nurse is incorrect?
“A visitor fell in the hallway after slipping because of a wet floor.”
“A physical assessment of the visitor reveals no obvious injuries.”
“Visitor refused medical attention, stated ‘I really am okay.’”
“Visitor refused wheelchair assistance and ambulated without difficulty.”
“A visitor fell in the hallway after slipping because of a wet floor.”
A client is receiving a tube feeding and has inadvertently pulled out the tube. The nurse has replaced the tube and is ready to restart the feeding. What step must be taken before starting the feeding?
The client needs to be reweighed.
The client needs to have tube placement verified, perhaps even by x-ray.
The client should be tested on semisolid foods before returning to tube feeding.
The client should receive bolus feedings until tube placement is confirmed by x-ray.
The client needs to have tube placement verified, perhaps even by x-ray.
The nurse is providing care for a patient scheduled for surgery to amputate gangrenous toes from the left foot. During the shift assessment, the nurse checks pedal pulses, skin color and warmth, and the level of pain. Which finding would prompt the nurse to perform an additional assessment?
The patient’s right lower leg and ankle are swollen.
The pedal pulses to the left foot are lower than 12 hr earlier.
The right lower extremity is pink in color and warm to the touch.
The level of pain in the left lower extremity is a level 6 on a 0 to 10 scale.
The patient’s right lower leg and ankle are swollen.
The nurse has applied sterile gloves to assist in surgery. Which activity by the nurse mandates that the nurse’s sterile gloves be changed?
The nurse bends to place an item in the trash can.
The nurse’s hands are kept between the waist and eyes.
The nurse’s hands are always held in the front of the body.
The nurse’s hands are never outside the nurse’s peripheral vision.
The nurse bends to place an item in the trash can.
6.57 g = __ mcg
0.044 mg = __ mcg
9,500 g = __ kg (Document to the tenth place)
6,570,000
44
9.5
as patient desires
as evidenced by
history of
within normal limits
dextrose 5% in water
AD LIB
AEB
H/O
WNL
D5W
The nurse is admitting a client for a diagnosis unrelated to nutrition; however, the client states, “I don’t eat gluten, but I don’t have celiac disease.” Which meal will the nurse expect the client to order?
Bean soup, cornbread with butter, and tapioca pudding
Ham and cheese sandwich on whole wheat bread, and fruit
Spaghetti with meat sauce, salad, and cake with butter frosting
Baked chicken breast, mashed potatoes with butter, and ice cream
Baked chicken breast, mashed potatoes with butter, and ice cream
When assessing a patient’s eyes, the nurse can shine a light into one of the patient’s eyes and both pupils should have a rapid constriction that is simultaneous and equal. This action is known as which of the following?
Consensual reflex
Accommodation response
PERRLA
Ptosis
Consensual reflex
The nurse calls the hospital housekeeping department to clean a room. The previous patient was diagnosed with hepatitis B. Which method of cleaning does the nurse recognize being used to make the room safe for the next patient?
Disinfection of all surfaces with chlorine bleach products
Sanitization of the floors with commercial cleaning products
Sterilization of the bed and over-bed table with steam cleaning
Sealing the room and using an antimicrobial gas to kill all pathogens
Disinfection of all surfaces with chlorine bleach products
21 tsp = __ Tbsp
600 gtt = __ tsp
8 oz = __ Tbsp
7
10
16
The nurse is planning interventions for a client experiencing nausea and vomiting after receiving chemotherapy. Which intervention is individualized for this client?
Encourage fluids
Avoid taking fluids while eating meals
Monitor intake and output and daily weights
Provide 8 ounces enriched milkshake mid-morning and mid-afternoon
Provide 8 ounces enriched milkshake mid-morning and mid-afternoon
The nurse is reviewing the daily recommended intake of water with a patient. The patient understands the need for 6 to 8 eight-ounce glasses of water daily, but asks when the amount should be increased. Which answer by the nurse is incorrect?
When the weather is hot or a person works in a hot environment.
When experiencing an infection from a bacterial or viral source.
When fluid is being retained due to cardiac function.
When exercising or participating in physical exertion.
When fluid is being retained due to cardiac function.
client presents with an apical pulse rate of 100 and a radial rate of 92. The difference in rates is referred to as:
pulse pressure.
sinus rhythm.
pulse deficit.
tachycardia.
pulse deficit.
The nurse is working in a hospital setting with patients admitted for multiple diagnoses. Which patient does the nurse recognize as requiring a sterile procedure?
A patient being treated for chronic obstructive pulmonary disease (COPD)
A patient who is prescribed to have an indwelling urinary catheter
A patient who needs assistance with eating due to a stroke
A patient who is being monitored after an allergic reaction
A patient who is prescribed to have an indwelling urinary catheter
62% of 3,567 = __ (Round to the tenth place)
22% of 800
62% of 104 = __ (Round to the tenth place)
2211.5
176
64.5
The nurse reviews a care plan written for a client. Which nursing diagnosis should the nurse delete from this plan?
“Pain related to abdominal incision”
“Altered sensory perception related to surgery”
“Chronic fatigue syndrome related to poor diet”
“Altered nutrition related to nausea and vomiting”
“Chronic fatigue syndrome related to poor diet”
The school nurse is talking about nutrition to a class of adolescents. Which comment by one of the adolescents will cause the nurse greatest concern?
“I love pizza and could eat it every day of the week.”
“My mother packs my lunch and includes the most awesome snacks.”
“When I work after school, I often miss dinner at home.”
“I never eat anything but small salads so that I can control my weight.”
“I never eat anything but small salads so that I can control my weight.”
Which patient(s), who need to ambulate, would be inappropriate to assign to an unlicensed assistive personnel (UAP)? Select all that apply.
The patient returning from abdominal surgery who is walking for the first time
The patient with severe postural hypotension
The patient who is steady on feet
The patient going for an initial walk after a stroke
The patient going for an initial walk after a stroke
The patient with severe postural hypotension
The patient returning from abdominal surgery who is walking for the first time
A patient was discharged after treatment for a staph infection. The blood pressure cuff and electronic thermometer were kept in the patient’s room to prevent transmission of the infection. The nurse bags and sends the equipment to be sterilized. Which method does the nurse recognize as being used for the process?
Autoclaving
Chemical disinfection
Gaseous disinfection
Ionizing radiation
Gaseous disinfection
22 x 2.2 = __ (Round to tenth place)
322 divided by 2.2 = __ (Round to the tenth place)
9/10% of 2,000 = __ (Round to hundredth place)
1/3% of 86 = __ (Round to the hundredth place)
141% of 980 = __ (Round to the tenth place)
48.4
146.4
18
0.29
1381.8