Fundamentals Fun Mix

A nurse is assessing/collecting data from a client. Which findings are objective data? (select all that apply)

• Respiratory rate is even and unlabored at 22/min.

• The client's partner states, "They had burning leg pain after walking 10 minutes."

• The client's pain rating is 3 on a scale of 0 to 10.

• The client's skin is consistent with genetic background, warm and dry.

• An assistive personnel reports that the client walked with a limp.

Answer explanation

A charge nurse is talking with a newly licensed nurse about interventions that require a provider's prescription and nursing interventions that are nurse-initiated. Which of the following interventions are

Nurse -initiated? (select all that apply)

• Inserting a nasogastric tube to relieve gastric distention

• Showing a client how to use progressive muscle relaxation

• Performing a daily bath after the evening meal

• Repositioning a client every 2 hr to reduce pressure risk injury

• Writing a prescription for morphine as needed for pain

A charge nurse is discussing the nursing process with a newly licensed nurse who is caring for a client.

Which statement by the newly licensed nurse matches the Planning step in the Nursing Process?

• "I will determine the most important client problems that we should address."

• "I will review the past medical history in the client's medical record to obtain more information about the client."

• "I will ask the patient if their nausea has resolved."

• "I will review objective and subjective client data to identify a potential client problem."

• "I will administer prescriptions from the provider."

A nurse is reviewing hand hygiene techniques with a group of assistive personnel. Which of the following instructions should the nurse include when discussing handwashing? (Select all that apply)

• Apply 3 to 5 ml of liquid soap to dry hands

• Wash the hands with soap and water for at least 15 seconds

• Rinse the hands with hot water

• Use a clean paper towel to turn off hand faucets

• Allow the hands to air-dry after washing

The nurse has prepared a sterile field for assisting a provider with a chest tube insertion. Which of the following events should the nurse recognize as contaminating the sterile field? (select all that apply)

• The provider drops a sterile instrument onto the near side of the sterile field

• The nurse moistens a cotton ball with sterile saline and places it on the sterile field

• The procedure is delayed 1 hr because the provider receives an emergency call

• The nurse turns to speak to someone who enters through the door behind the nurse

• The client's hand brushes against the outer edge of the sterile field

Which of the following actions should the nurse take when demonstrating an empathic presence to a client? (select all that apply)

• Use an open posture

• Write down what the client says to avoid forgetting details

• Establish and maintain eye contact

• Nod in agreement with the client throughout the conversation

• Sit facing the client

A nurse is caring for a client who is concerned about being discharged to home with a new colostomy because of being an avid swimmer. Which of the following statements should the nurse make? (select all that apply)

• "You will do great! You just have to get used to it."

• "Why are you so worried about going home?"

• "Your daily routines will be different when you get home."

• "Tell me about the support systems you'll have when you get home."

• "It sounds like you are not sure how having a colostomy will affect swimming."

A nurse is monitoring a client for adverse effects following the administration of an opioid. Which of the following effects should the nurse identify as an adverse effect of opioids? (select all that apply)

• Urinary incontinence

• Diarrhea

• Bradypnea

• Orthostatic hypotension

• Nausea

A nurse is caring for a client who is receiving morphine via a patient-controlled analgesia (PCA) infusion device after abdominal surgery. Which of the following statements indicates that the client knows how to use the device?

• "I'll wait to use the device until it's absolutely necessary."

• "I'll be careful about pushing the button too much so I don't overdose."

• "I should tell the nurse if the pain doesn't stop while I am using this device."

• "I will ask my adult child to push the dose button while I am sleeping."

A nurse is assessing a client who is reporting pain despite taking analgesia. Which of the following actions should the nurse take to determine the intensity of the client's pain?

• Ask the client what precipitates the pain

• Question the client about the location of the pain

• Offer the client a pain scale to measure their pain

• Use open-ended questions to identify the client's pain sensations