Fundamentals of Nursing 1

Fundamentals of Nursing 1

• The nurse is assisting with procedural moderate sedation (conscious sedation) at a client’s bedside. The

unlicensed assistive personnel (UAP) comes to the door and indicates that the client in the next room needs the nurse right now. How should the nurse responds?

• Ask the UAP to go back and ask the client what the current needs are.
• Ask the UAP to stay and take over while the nurse goes to check on the client in the next room.
• Tell the UAP to inform the client in the next room that the nurse will be there shortly.
• Tell the UAP to tell the charge nurse about the needs of the client in the next room.

• The nurse is performing a central line tubing change when the client suddenly begins gasping for air and

writing. Order the interventions by priority. All options must be used.

• Administer oxygen as needed.
• Clamp the catheter.
• Notify the health care provider (HCP)
• Place the client in Trendelenburg position on the left side.
• Stay with the client and provide reassurance.

• The nurse is feeding a confused client via a small-bore nasoenteric tube. The nurse observes the client

pulling at the tube and then notices an increase in external tube length from the original exit mark. After immediately stopping the feeding, which action is appropriate for the nurse to take next?

• Advance the tube to the original exit mark, check gastric aspirate pH, and resume feeding.
• Contact the health care provider to request a prescription for hand mitts.
• Contact the health care provider to request an x-ray to verify tube placement.
• Reinsert the guide wire and advance the tube to its original exit mark.

• A client with a dislocated shoulder is prescribed a shoulder sling. The nurse applies the sling and evaluates

the fit before discharge from the emergency room. Which assessment finding indicates an incorrect fit?

• The elbow is flexed at 90degrees.
• The hand is held slightly below elbow level.
• The sling ends in the middle of the palm with fingers visible.
• The sling supports the wrist.

• The graduate nurse (GN) is inserting an oropharyngeal airway into a client emerging from general

anesthesia. Which action by the GN causes the nurse preceptor to intervene?

• Measures the oropharyngeal airway against the cheek and jaw angle before insertion.
• Rotates the device tip downward once it reaches the soft palate.
• Suctions secretions from the mouth and pharynx prior to device insertion.
• Tapes the external portion of the inserted oropharyngeal airway to the client’s cheek.

• The nurse observes a student nurse administer a tuberculin skin test using the intradermal route. The nurse

intervenes when the student performs which action?

• Advances tip of the needle through epidermis until the bevel is no longer visible under the skin.
• Choose 1 mL tuberculin syringe with a 27-gauge ¼ inch needle; dons clean gloves.
• Injects medication slowly while raising a small wheal (bleb) on the skin.
• Inserts needle at a 10-degree angle almost parallel to skin with the bevel up.

• The nurse is to administer an albuterol nebulizer treatment to a client with acute bronchospasm. The

prescribed dosage is 5 mg every 4 hours. The available solution is albuterol (0.083%) inhaled, 2.5 mg/3 mL.how many milliliters (mL) should the nurse administer with each dose? Record your answer as a whole number.

Answer: _____mL

• The nurse inserts a urinary catheter into a female client who has not voided fro 6 hours. No urine is

returned. What action should the nurse take next?

• Leave the catheter in place and insert a new catheter higher up in the perineal area.
• Leave the catheter in place for 30 minutes and then recheck.
• Notify the prescribing health care provider that there is an obstruction.
• Remove the catheter and reinsert it at a position higher that the initial insertion.

• The student nurse is applying a condom catheter for an ambulatory client who is uncircumcised and

incontinent of urine. The precepting nurse should intervene when the student performs which action?

• Attaches the drainage tubing to a lower leg collection.
• Leaves a 1-2 in (2.5-5 cm) space at the tip of the condom.
• Retracts the foreskin before applying the condom sheath.
• Uses elastic adhesive in a spiral fashion to secure device.

• The nurse is evaluating a return demonstration by the client of a dry dressing change. Which action by the

client would cause the nurse to intervene?

• Client applies sterile adhesive dressing over gauze without touching the wound bed.
• Client applies sterile gauge moistened with sterile saline to wound surface.
• Client cleanses site with a sterile saline swab in a spiral pattern from the center out.
• Client removes old dressing with clean gloves and checks site for signs of infection.

• The nurse is drawing blood from a client’s peripheral vein for laboratory specimens. Which of the following

are correct nursing actions? Select all that apply.

• Do not leave a tourniquet on more than 1 minute while looking for vein.
• Draw the specimen while the skin is still wet with the alcohol prep.
• If pulsating red blood, withdraw the needle and apply pressure for 5 minutes.
• Use a highly visible vein on the ventral side of the client’s wrist.
• Vigorously shake the specimen tube to mix obtained blood with anticoagulant solution.

• The nurse is suctioning the artificial airway of a conscious client. Which actions demonstrate correct

technique? Select all that apply.

• Apply suction for no longer than 5-10 seconds.
• Insert catheter with low, intermittent suction applied.
• Set suction higher than 130 mm Hg for thick, copious secretions.
• Wait at least 1 minute between suction passes.
• Withdraw catheter immediately if client begins coughing.

• The nurse has received a prescription from the health care provider to administer 80 mg of

methylprednisolone IV piggyback. The available vial contains 125 mg in 2 mL. Select the syringe containing the appropriate amount of medication to be administered.

• The nurse prepares equipment for insertion of a large-bore nasogastric (NG) tube for a hospitalized client.

Which actions should the nurse take to measure and mark the tube? Select all that apply.

• Fold tube in half and mark at the halfway point.
• Extend tape measure from naris to stomach.
• Measure from tip of nose to earlobe to xiphoid process.
• Place a small piece of tape at the point of measurement.
• Use rubber clamp after measuring to mark the point of measurement.

• A 55-year-old male client has a 16-Fr indwelling urethral catheter with a 5-mL balloon inserted to relieve

postoperative urinary retention. The nurse observes urine leaking from the insertion site, past the catheter.What is the nurse’s first action?

• Check the urethral catheter and drainage tubing.
• Irrigate the catheter with 30 mL of sterile normal saline.
• Notify the healthcare provider.
• Remove and reinsert the next-larger-size catheter.

• The student nurse verbalizes the procedure for obtaining a wound culture to the nurse preceptor. Which of

the following statements by the student indicate a correct understanding? Select all that apply.

• “I will apply the prescribed bacitracin ointment after collecting the wound culture.”
• “I will cleanse the wound by gently flushing it with normal saline.”
• “I will obtain a sample of the drainage accumulated since the last dressing change.”
• “I will perform hand hygiene and apply new gloves before obtaining the wound culture.”
• “I will swab the wound from the outermost margin toward the center.”

• Which of these are correct nursing actions related to client positioning? Select all that apply.

• Position client in high Fowler’s for a paracentesis related to end-stage cirrhosis.
• Position client on left side after liver biopsy.
• Position client on side with head, back, and knees flexed after lumbar puncture.
• Position client Trendelenburg on left side if air embolism is suspected.
• Position client with arm raised above head for chest tube placement.

• The nurse cares for a client receiving intermittent peritoneal dialysis who is prescribed strict intake and

output monitoring with calculation of net fluid balance each shift. Calculate the total net fluid balance for the shift. Record the answer using whole number.

Answer:

Intake and output record Time Oral intake Parenteral Other intake Output

0700 150 mL vancomycin IV

0900 240 mL coffee 1500 mL dialysate 1100 120 mL tea 1300 100 mL cefepime IV 1400 mL dialysate outflow 1500 180 mL juice

• The nurse is preparing to infuse 2 units of packed red blood cells (PRBCs) to a client with a gastrointestinal

bleed. Which actions should the nurse take. Select all that apply.

• Assess client’s vital signs.
• Infuse both units simultaneously.
• Obtain a Y tubing set and prime with normal saline (NS).
• Plan to remain with client during the 1

st 15 minutes of transfusion.e.Set infusion pump to deliver unit over 30 to 45 minutes.

• Spike filtered intravenous (IV) tubing with dextrose 5% water (D5W).

• A client is receiving blood transfusion. Fifteen minutes after the transfusion starts, the nurse notes a drop

in blood pressure from 110/70 to 84/50 mm Hg. The client reports “feeling a little cold”. Based on this assessment, in what order should the nurse complete the following actions? All options must be used.

Unordered Options Your Response

• Administer vasopressor.
• Collect urine specimen.
• Document the occurrence.
• Stop the blood transfusion.
• Using new tubing, infuse normal saline into the vein.

• The healthcare provider prescribes a continuous IV infusion of regular insulin at 5 units/hr. The infusion

bag contains 50 units of regular insulin in 100 mL of normal saline solution. At what rate in milliliters per hour (mL/hr) does the nurse set the IV pump? Record your answer using a whole number.

Answer: _____mL/hr

• The healthcare provider prescribes 2 mEq (2 mmol)/kg of 8.4% sodium bicarbonate IV to be administered

over the next 4 hours. The client weighs 150 lb, and the pharmacy supplies the following IV solution: 8.4% sodium bicarbonate in 1000 mL of D5W with 150 mEq (150 mmol) of sodium bicarbonate. At what rate in milliliters per hour (mL/hr) should the nurse set the infusion pump? Record your answer using a whole number.

Answer: _____mL/hr