Fundamentals
A nurse is caring for a client who developed hypoglycemia following an insulin injection. The client is conscious and responds appropriately to verbal stimuli. Which of the following medications should the nurse plan to administer first?
A. Oral glucose tablet
B. 50% dextrose intravenously
C. Glucagon intramuscularly
D. Epinephrine intravenously
A. Oral glucose tablet
Evidence -based practice indicates that a client who has mild hypoglycemia and is conscious and able to swallow should receive an oral agent such as an oral glucose tablet. If the client is unresponsive to the oral glucose, another, more invasive form of treatment can be initiated.
A nurse is providing support for the parent of a child who has a new diagnosis of terminal brain tumor. The nurse should expect the parents to experience which of the following stages of grief first?
A. Denial
B. Bargaining
C. Anger
D. Depression
A. Denial
Evidence-based practice indicates the nurse should first expect the parents to experience denial. Denial is the first stage of grief and is followed by anger, bargaining, depression, and finally acceptance.
A nurse is assessing a client who delivered vaginally 8 hours ago. The nurse notes that the client’s fundus is 2 fingerbreadths above the umbilicus and has shifted to the left, and there Is a large amount of lochia rubra on the perineal pad. Which of the following actions should the nurse take first>?
A. Administer analgesia
B. Administer carboprost IM
C. Assist the client to the toilet
D. Obtain a blood specimen to test the Hgb levels
C. Assist the client to the toilet
Evidence-based practice indicates that the nurse should first help the client empty her bladder. Displacement of the fundus to the left indicated that the cause of the excessive bleeding is uterine atony due to bladder distension, so this action is the nurse’s priority.
A nurse is caring for a client who has acute renal failure. Which of the following assessment provides the most accurate measure of the client’s fluid status?
A. Daily weights
B. Blood pressure
C. Specific gravity
D. Intake and output
A. Daily weights
According to evidence-based practice priority setting framework, daily weight provides important info about the client’s fluid status. A gain or loss 1 kg (2.2 lbs) indicates a gain or loss of 1 L of fluid; therefore, weighing the client daily will provide the most accurate fluid status measurement.
A nurse is providing anticipatory guidance about the accidental ingestion of toxic substances to the parents of a toddler. The nurse should instruct the parents to take which of the following actions first if the child ingests a hazardous substance?
A. Give the toddler milk.
B. Go to the emergency department.
C. Call the poison control center.
D. Induce vomiting
C. Call the poison control center.
According to evidence-based practice, the nurse should instruct the parents to call the poison control center, which will then identify what further actions parents should take.
A nurse is helping a clients change his hospital gown. The client has an IV infusion via an infusion pump. Which of the following actions should the nurse take first?
A. Remove the sleeve of the gown from the arm without the IV line.
B. Slow the infusion using the roller clamp
C. Disconnect the IV line from the pump
D. Bring the IV solution and tubing from the outside to the inside of the sleeve of the gown
A. Remove the sleeve of the gown from the arm without the IV line.
According to evidence-based practice, the nurse should first remove the gown from the clients arm without the IV line. Beginning this process will enable the nurse to move the gown fully off the client before stopping the system to remove the gown from the line, resulting in minimal interruption of the IV flow.
A nurse is performing an assessment of a newly admitted client. To establish trust, which of the following actions should the nurse perform in the orientation phase of the nurse-client relationship?
A. Inform the client that the admission is confidential
B. Introduce the client to other clients in the day room
C. Assist the client in facilitating a behavioral change
D. Determine which coping strategies the client used in the past
A. Inform the client that the admission is confidential
According to evidence-based practice, the nurse should inform the client about confidentiality during the orientation phase of the nurse-client relationship. This action helps establish trust between the nurse and the client.
A nurse is performing a breast examination for a female client. Which of the following techniques should the nurse use first?
A. Inspect both breasts simultaneously
B. Squeeze the nipples
C. Palpate the breast and tail of Spence
D. Palpate the axillary lymph nodes
A. Inspect both breasts simultaneously
According to evidence-based practice, the nurse should first inspect both breasts with the client's arms in several different positions to look for asymmetry, masses, retraction, lesions, inflammation, and dimpling.
A nurse is teaching a client who has a spinal cord injury to perform intermittent urinary self-catheterization at home after discharge. Which of the following statements indicates that the client understands the procedure?
A. I’ll drink less water, so I don’t have to catheterize myself too often.
B. I must use a sterile technique for each of the catheterizations.
C. I should stop the catheterization when I have removed 150 mL of urine.
D. I will perform intermittent self-catherization every 2 to 3 hr.
D. I will perform intermittent self-catherization every 2 to 3 hr.
The client might initially require self-catherization every 2 to 3 hrs, with a frequency eventually increasing to every 4 to 6 hrs. A longer interval can result in bladder distension and an increase risk of urinary tract infections
A nurse is caring for a school-aged child who is having a tonic-clonic seizure. Which of the following actions should the nurse perform first?
A. Position the child on his side
B. Measure the child’s vital signs
C. Loosen any restrictive clothing
D. Check the child for head injuries
A. Position the child on his side
Using evidence-based practice, the nurse should first position the child on his side. Salivation increases and the swallowing reflex is lost during a tonic-clonic seizure, placing the child at risk for aspiration. It is essential to maintain the airways during a seizure.
A nurse is teaching a client about lifestyle changes to manage a chronic illness. Which of the following strategies should the nurse use first to help the client make a commitment to these lifestyle changes?
A. Identify the risks of nonadherence
B. Schedule learning sessions to demonstrate the psychomotor skills the client will need
C. Provide clearly written and easy to understand materials
D. Help the client identifies ways that these changes will result in positive personal outcomes
D. Help the client identifies ways that these changes will result in positive personal outcomes
According to evidence-based practice, the motivation to change must precede taking steps to make the change. Therefore, helping clients identify ways that the changes will promote positive outcomes should precede other educational strategies for making the changes. The client should first see how the changes directly affect his/her life, thus enhancing the motivation to make the changes.
A nurse is participating in an ethics committee meeting about a client who has a history of alcohol use disorder and needs a liver transplant. Which of the following actions should the committee take first?
A. Collect information related to the issue.
B. Consider the possible choices of action.
C. Make a decision regarding transplant recommendation.
D. Justify the recommendation for or against a transplant.
A. Collect information related to the issue.
According to evidence-based practice, the committee should take the first step in ethical decision-making by identifying the ethical issue and problem. This step includes asking questions to define the issue and the complexities of the situation.
A nurse is caring for a client who is 38 weeks of gestation and is receiving an oxytocin IV for labor augmentation. The nurse notes variable decelerations on the FHR tracing. Which of the following actions should the nurse take first?
A. Place the client in a side-lying position
B. Discontinue the oxytocin infusion
C. Apply oxygen to the client via face mask
D. Check for umbilical cord prolapse
A. Place the client in a side-lying position
According to evidence-based practice, the nurse should act quickly to restore the oxygen supply to the fetus. Variable decelerations reflect an umbilical cord prolapse; therefore, the nurse should act immediately to help shift the pressure of the presenting part off the cord.
A nurse is preparing an in-service presentation about assessing clients who are having an acute myocardial infarction (MI). What is the most common assessment finding with acute MI?
A. Dyspnea
B. Pain in the shoulder and left arm
C. Substernal chest pain
D. Palpitations
C. Substernal chest pain
Evidence-based practice indicates that the most common manifestation of acute MI is substernal chest pain that does not subside with rest or nitroglycerin. Therefore, nurses should make pain management with morphine a priority to reduce myocardial oxygen demand and increase oxygenation.
A nurse is teaching the parent of an infant about food allergies. Which of the following is the most common food allergy in children?
A. Cow’s milk
B. Wheat bread
C. Corn syrup
D. Eggs
A. Cow’s milk
According to evidence-based practice, cows’ milk is the most common food allergy in children. Some children are sensitive to the protein casein found in cow’s milk. They have difficulty metabolizing casein and are, therefore, allergic to cow’s milk.
A nurse is preparing to administer an intramuscular injection to a young adult client. Which of the following injection sites in the safest for this client?
A. Vastus lateralis
B. Dorsogluteal
C. Deltoid
D. Ventrogluteal
D. Ventrogluteal
According to evidence-based practice, the ventrogluteal site is the safest injection site for all adults because it contains thick gluteal muscles and does not contain major nerves or blood vessels.
A nurse is caring for a client who is experiencing a panic attack. Which of the following actions should the nurse take?
A. Discuss new relaxation techniques
B. Show the client how to change the behavior
C. Distract the client with a television show
D. Stay with the client and remain quiet
D. Stay with the client and remain quiet
During a panic attack, quietly remain with the client. This promotes safety and reassurance without additional stimuli.
A nurse is caring for a client at 35 weeks gestation who has severe preeclampsia. Which of the following assessments provides the most accurate information regarding the client’s fluid and electrolyte status?
A. Blood pressure
B. Intake and output
C. Daily weights
D. Severity of edema
C. Daily weights
Evidence-based practice indicates that daily weight is the most accurate assessment to determine a client’s fluid and electrolyte status.
A nurse is caring for a client who is experiencing autonomic dysreflexia due to a C5 spinal cord injury. After checking the client’s vital signs, which of the following actions should the nurse perform next?
A. Administer nifedipine
B. Place client in high-fowlers position
C. Check for urinary retention
D. Check for fecal impaction
B. Place client in high-fowlers position
According to evidence-based practice, the nurse should first place the client in high-fowlers position to decrease the clients blood pressure and reduce the risk of end-organ damage from the sudden rise in blood pressure.
A nurse is planning to implement relaxation strategies with a young child prior to a painful procedure. Which of the following actions should the nurse take?
A. Ask the child to hold a breath and blow it out slowly.
B. Ask the child to describe a pleasurable event.
C. Bounce the child gently while holding him upright
D. Rock the child using long, rhythmic movements
D. Rock the child using long, rhythmic movements
The nurse can implement relaxation strategies by sitting with the child in a well-supported position such as against the chest and rocking or swaying back and forth in long, wide movements
A charge nurse in an emergency department is notified by the county’s emergency medical services of a multiple-casualty crash involving a truck carrying radioactive waste. Which of the following actions should the nurse take first?
A. Designate a decontamination area to accommodate clients who are irradiated.
B. Notify the admissions office to clear as many critical care beds as possible.
C. Clear the department of all non-urgent clients and move those awaiting admission to a holding area.
D. Determine the number of casualties the emergency department can accommodate.
C. Clear the department of all non-urgent clients and move those awaiting admission to a holding area.
Evidence-based practice indicates the nurse should first clear the emergency department of non-urgent clients and open as many treatment areas as possible. Casualties of the crash will be brought to the emergency department, so the nurse must make room to accommodate the high number of clients.
A nurse on an inpatient mental health unit if attending an interdisciplinary treatment team meeting for a client who has bipolar disorder with rapid cycling. The client is being prepared for discharge following his fourth admission in the last year. Which of the following referrals should the nurse make for the client first?
A. Assertive community treatment
B. Support group
C. Private counseling
D. Vocational rehabilitation service
A. Assertive community treatment
Evidence-based practice indicates the nurse should first refer the client to an assertive community treatment (ACT). An ACT program should be most beneficial for this client who has bipolar disorder with rapid cycling, as a professional help will be available to the client 24 hours a day for crisis management. A multidisciplinary team approach assists clients in managing their mental illness so impatient hospitalizations can be avoided.
A nurse is reinforcing teaching with a client who asks about using essential oils for her labor and delivery expected to occur next month. Which of the following responses should the nurse make?
A. "Studies show that jasmine has an antidepressant effect during labor."
B. "Studies show that the use of lavender is effective for strengthening contractions."
C. "Studies do not promote diffusing essential oils during labor due to the possibility of respiratory compromise."
D. "Studies show no evidence that essential oils improve labor outcomes."
D. "Studies show no evidence that essential oils improve labor outcomes."
Although evidence-based practice does not show any evidence that essential oil use improves labor outcomes, it is not associated with harm unless an allergic reaction is noted from topical application. Any effectiveness is due to an individual perception regarding nonpharmacological pain management.
A nurse is preparing an in-service presentation about the management of myocardial infarction (MI). Death following MI is often a result of which of the following complications?
A. Cardiogenic shock
B. Dysrhythmias
C. Heart failure
D. Pulmonary edema
B. Dysrhythmias
According to evidence-based practice, dysrhythmias (specifically ventricular fibrillation) are the most common cause of death following MI. Therefore, nurses should monitor clients' ECGs carefully for dysrhythmias and report and treat them immediately.
A nurse is caring for an infant who has a myelomeningocele. Which of the following actions should the nurse include in the preoperative plan of care?
A. Assist the caregiver with cuddling the infant
B. Assess the infants temperature rectally
C. Place the infant in a supine position
D. Apply a sterile, moist dressing on the sac
D. Apply a sterile, moist dressing on the sac
A sterile moist nonadherent dressing is placed on the sac to keep it moist until surgery. This should be in preoperative care.