Foundational Nursing
A new RN nurse is about to insert a nasogastric tube into a client with Guillain-Barre Syndrome. To determine the accurate measurement of the length of the tube to be inserted, the nurse should:
A. Place the tube at the tip of the nose, and measure by extending the tube to the earlobe and then down to the top of the sternum.
B. Place the tube at the tip of the nose and measure by extending the tube to the earlobe and then down to the xiphoid process.
C. Place the tube at the tip of the nose, and measure by extending the tube down to the chin and then down to the top of the xiphoid process.
D. Place the tube at the base of the nose and measure by extending the tube to the earlobe and then down to the top of the sternum.
B. Place the tube at the tip of the nose and measure by extending the tube to the earlobe and then down to the xiphoid process.
Estimate the length of insertion by measuring the distance from the tip of the nose, around the ear, and down to just below the left costal margin. This point can be marked with a piece of tape on the tube. When using the Salem sump NG tube (Kendall, Mansfield, MA) in adults, the estimated length usually falls between the second and third preprinted black lines on the tube.
Nurse Skye is assigned to the cardiac unit caring for four clients. He is preparing to do initial rounds. Which client should the nurse assess first?
A. A client scheduled for cardiac ultrasound this morning.
B. A client with syncope being discharged today.
C. A client with chronic bronchitis on nasal oxygen.
D. A client with diabetic foot ulcer that needs a dressing change.
Correct Answer: C. A client with chronic bronchitis on nasal oxygen.
A nurse is changing the central line dressing of a client receiving parenteral nutrition (PN) and notes that there is redness and drainage at the insertion site. The nurse next assesses which of the following?
A. Time of last dressing change.
B. Allergy.
C. Client's temperature.
D. Expiration date.
Correct Answer: C. Client’s temperature.
Redness at the catheter insertion site is a possible sign of infection. The nurse would next assess for other signs of infection. Of the options given, the temperature is the next item to assess. TPN requires a chronic IV access for the solution to run through, and the most common complication is an infection of this catheter. Infection is a common cause of death in these patients, with a mortality rate of approximately 15% per infection, and death usually results from septic shock.
Nurses and other healthcare providers often have difficulty helping a terminally ill patient through the necessary stages leading to acceptance of death. Which of the following strategies is most helpful to the nurse in achieving this goal?
A. Taking psychology courses related to gerontology.
B. Reading books and other literature on the subject of thanatology.
C. Reflecting on the significance of death.
D. Reviewing varying cultural beliefs and practices related to death.
Correct Answer: C. Reflecting on the significance of death
According to thanatologists, reflecting on the significance of death helps to reduce the fear of death and enables the health care provider to better understand the terminally ill patient’s feelings. It also helps to overcome the belief that medical and nursing measures have failed, when a patient cannot be cured. Thanatology is the science and study of death and dying from multiple perspectives—medical, physical, psychological, spiritual, ethical, and more.
The nurse caring for a client with a pneumothorax and who has had a chest tube inserted notes continuous gentle bubbling in the suction control chamber. What action is most appropriate for the nurse?
A. Increase the suction pressure so that the bubbling becomes vigorous.
B. Do nothing since this is an expected finding.
C. Immediately clamp the chest tube and notify the physician.
D. Check for an air leak because the bubbling should be intermittent.
Correct Answer: B. Do nothing since this is an expected finding.
Continuous gentle bubbling should be noted in the suction control chamber. Bubbling should be continuous in the suction control chamber and not intermittent. The water level in the suction chamber should be at the prescribed level and gentle bubbling should be observed. The level may drop due to evaporation or over-vigorous bubbling, if this occurs top fluid level up as per manufacturer’s instructions.
Continuous type of feedings is administered over a __ hour period?
A. 4.
B. 12.
C. 24.
D. 36.
C. 24.
Continuous feeding is administered for 24 hours. An infusion pump regulates the flow. Continuous drip feeding is delivered by either gravity drip or infusion pump. The infusion pump is a better method of delivery than gravity drip. The flow rate of gravity drip may be inconsistent and, therefore, needs to be checked frequently.
A client with multiple injuries is rushed to the ED after a head-on car collision. Which assessment finding takes priority?
A. Irregular apical pulse
B. Ecchymosis in the flank area
C. A deviated trachea
D. Unequal pupils
Correct Answer: C. A deviated trachea
A client has returned to his room following an esophagoscopy. Before offering fluids, the nurse should give priority to assessing the client’s:
A. Level of consciousness
B. Movement of extremities
C. Urinary output
D. Gag reflex
Correct Answer: D. Gag reflex
A nurse is conducting an assessment of an American Indian woman who has come to the clinic complaining of a headache. The patient tells the nurse that the medicines prescribed by the tribal healer have done some good. What is the appropriate response of the nurse at this time?
A. Tell me about these medicines and how often you are using them.
B. I advise you to refrain from taking those medicines from the tribal healer.
C. Could these medicines cause your headaches?
D. Maybe you should increase the frequency of the healer's medicines.
Correct Answer: A. Tell me about these medicines and how often you are using them.
Asking the patient about the nature of these medicines and how often the client uses them allows the nurse to collect data about the medicines and their uses, to learn more about the practices used by this patient to improve her health, and to check for a potential drug interaction before prescribing other medications or treatment.
The most important nursing intervention to correct skin dryness is:
A. Consult the dietitian about increasing the patient’s fat intake, and take necessary measures to prevent infection.
B. Ask the physician to refer the patient to a dermatologist, and suggest that the patient wear home-laundered sleepwear.
C. Encourage the patient to increase his fluid intake, use non-irritating soap when bathing the patient, and apply lotion to the involved areas.
D. Avoid bathing the patient until the condition is remedied, and notify the physician.
Correct Answer: C. Encourage the patient to increase his fluid intake, use non-irritating soap when bathing the patient, and apply lotion to the involved areas.
Dry skin will eventually crack, ranking the patient more prone to infection. To prevent this, the nurse should provide adequate hydration through fluid intake, use non irritating soaps or no soap when bathing the patient, and lubricate the patient’s skin with lotion. In most cases, dry skin responds well to lifestyle measures, such as using moisturizers and avoiding long, hot showers and baths. Moisturizers provide a seal over the skin to keep water from escaping. Apply moisturizer several times a day and after bathing.
A client with Congestive heart failure is about to take a dose of furosemide (Lasix). Which of the following potassium levels, if noted in the client’s record, should be reported before giving the due medication?
A. 5.1 mEq/L.
B. 4.9 mEq/L.
C. 3.9 mEq/L.
D. 3.3 mEq/L.
Correct Answer: D. 3.3 mEq/L.
The normal potassium level is 3.5 to 5.5 mEq/L. Low potassium levels can be dangerous, especially for people with CHF. Low potassium can cause fatal heart arrhythmias. An abnormal serum K+ level is associated with an increased risk of ventricular arrhythmia and sudden cardiac death (SCD) and these patients are generally prescribed furosemide and potassium chloride (KCl).
Several people were killed and injured in a recent industrial explosion. The victims are being interviewed and assessed by the nurses for possible psychiatric crises. Which client has the greatest risk for posttraumatic distress disorder?
A. An individual who was injured and trapped for 8 hours before rescue.
B. A person who saw the death of a co-worker during the blast.
C. An individual who recently discovered that her daughter was killed in the incident.
D. A person who repeatedly watched television coverage of the event.
Correct Answer: A. An individual who was injured and trapped for 8 hours before rescue.
An 8-year-old is admitted with a sore throat, drooling, muffled phonation, high pitched-sound upon breathing (stridor), and a temperature of 102°F. The nurse should immediately notify the doctor because the child’s symptoms are suggestive of:
A. Primary Ciliary Dyskinesia
B. Subglottic hemangioma
C. Sinusitis
D. Epiglottitis
Incorrect
Correct Answer: D. Epiglottitis
Which statement would best explain the role of the nurse when planning care for a culturally diverse population? The nurse will plan care to:
A. Include care that is culturally congruent with the staff from predetermined criteria.
B. Focus only on the needs of the client, ignoring the nurse’s beliefs and practices.
C. Blend the values of the nurse that are for the good of the client and minimize the client’s individual values and beliefs during care.
D. Provide care while aware of one’s own bias, focusing on the client’s individual needs rather than the staff’s practices.
Correct Answer: D. Provide care while aware of one’s own bias, focusing on the client’s individual needs rather than the staff’s practices
Without understanding one’s own beliefs and values, a bias or preconceived belief by the nurse could create an unexpected conflict or an area of neglect in the plan of care for a client (who might be expecting something totally different from the care). During assessment values, beliefs, practices should be identified by the nurse and used as a guide to identify the choices by the nurse to meet specific needs/outcomes of that client. Therefore identification of values, beliefs, and practices allows for planning meaningful and beneficial care specific for this client.
Which instruction should be included in the discharge teaching for the client with cataract surgery?
A. Over-the-counter eye drops can be used to treat redness and irritation
B. The eye shield should be worn at night
C. It will be necessary to wear special cataract glasses
D. A prescription for medication to control post-operative pain will be needed
Correct Answer: B. The eye shield should be worn at night
Nurse Aaron is inserting a nasogastric tube to a stroke client. He understands that the best position for the insertion is?
A. Low Fowler’s.
B. Sims position.
C. Trendelenburg.
D. High Fowler’s.
Correct Answer: D. High Fowler’s.
The best position during a nasogastric tube insertion is sitting or High Fowler’s position in order to prevent the risk of aspiration. Position patient sitting up at 45 to 90 degrees (unless contraindicated by the patient’s condition), with a pillow under the head and shoulders. This allows the NG tube to pass more easily through the nasopharynx and into the stomach.
During the shift of a triage nurse in the Emergency Department (ED), the following clients arrive. Which client needs the most rapid response to protect other clients in the ED from infection?
A. A 72-year-old who must undergo tuberculosis (TB) testing after being exposed to TB during a recent international airplane flight.
B. A 58-year-old who has a history of a methicillin-resistant Staphylococcus aureus (MRSA) abdominal wound infection.
C. A 7-year-old who has a new pruritic rash and a possible chickenpox infection.
D. A 4-year-old who has paroxysmal coughing and whose sibling has pertussis.
Correct Answer: C. A 7-year-old who has a new pruritic rash and a possible chickenpox infection
The nurse is teaching the client with insulin-dependent diabetes the signs of hypoglycemia. Which of the following signs is associated with hypoglycemia?
A. Nausea
B. Flushed skin
C. Tremulousness
D. Slow pulse
Correct Answer: C. Tremulousness
What should the nurse do when planning nursing care for a client with a different cultural background? The nurse should:
A. Allow the family to provide care during the hospital stay so no rituals or customs are broken.
B. Identify how these cultural variables affect the health problem.
C. Speak slowly and show pictures to make sure the client always understands.
D. Explain how the client must adapt to hospital routines to be effectively cared for while in the hospital.
Correct Answer: B. Identify how these cultural variables affect the health problem.
Without assessment and identification of the cultural needs, the nurse cannot begin to understand how these might influence the health problem or health care management. Culture is influential at many levels in health, ranging from the formation of new diagnostic groups to the diagnosis of disease to the determination of what is called a disease or no symptoms and disease cues
The physician has prescribed Cytoxan (cyclophosphamide) for a client with nephrotic syndrome. The nurse should:
A. Provide additional warmth for swollen, inflamed joints
B. Bathe the client using only mild soap and water
C. Encourage the client to drink extra fluids
D. Request a low-protein diet for the client
Correct Answer: C. Encourage the client to drink extra fluids
A client with pleural effusion is scheduled to have a thoracentesis. The nurse on duty will assist the client to which position during the procedure?
A. Lying in bed on the unaffected side with the head of the bed elevated about 45°.
B. Forward side-lying position with head of bed flat.
C. Lying in bed on the affected side with the head of the bed elevated about 45°.
D. Supine position with both arms extended.
Correct Answer: A. Lying in bed on the unaffected side with head of bed elevated about 45°.
During thoracentesis, to facilitate removal of pleural fluid from the pleural space, position the client sitting on the edge of the bed, leaning over a bedside table with the feet supported on a stool, or lying in bed on the unaffected side with head of bed elevated about 45°.
The charge nurse is making assignments for the next shift. Which patient should be assigned to the fairly new nurse (6 months experience) pulled from the surgical unit to the medical unit?
A. A 58-year old on airborne precautions for tuberculosis (TB).
B. A 68-year old just returned from bronchoscopy and biopsy.
C. A 72-year old who needs teaching about the use of incentive spirometry.
D. A 69-year old with COPD who is ventilator dependent.
Correct Answer: C. A 72-year old who needs teaching about the use of incentive spirometry.
The nurse is caring for a client admitted with suspected myasthenia gravis. Which finding is usually associated with a diagnosis of myasthenia gravis?
A. Ascending paralysis and loss of motor function
B. Visual disturbances, including diplopia
C. Cogwheel rigidity and loss of coordination
D. Progressive weakness that is worse at the day’s end
Correct Answer: D. Progressive weakness that is worse at the day’s end
A client is hospitalized in the end stage of terminal cancer. His family members are sitting at his bedside. What can the nurse do to best aid the family at this time?
A. Limit the time visitors may stay so they do not become overwhelmed by the situation.
B. Avoid telling family members about the client’s actual condition so they will not lose hope.
C. Discourage spiritual practices because this will have little connection to the client at this time.
D. Find simple and appropriate care activities for the family to perform.
Correct Answer: D. Find simple and appropriate care activities for the family to perform.
It is helpful for the nurse to find simple care activities for the family to perform, such as feeding the client, washing the client’s face, combing hair, and filling out the client’s menu. This helps the family demonstrate their caring for the client and enables the client to feel their closeness and concern. a. Older adults often become particularly lonely at night and may feel more secure if a family member stays at the bedside during the night.
Before administering a client’s morning dose of Lanoxin (digoxin), the nurse checks the apical pulse rate and finds a rate of 52. The appropriate nursing intervention is to:
A. Record the pulse rate and administer the medication
B. Administer the medication and monitor the heart rate
C. Withhold the medication and notify the doctor
D. Withhold the medication until the heart rate increases
Correct Answer: C. Withhold the medication and notify the doctor