Exam (elaborations)
Exam (elaborations) NURSING FUNDAMENTAL LATEST EDITION 1 QUESTIONS
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Exam (elaborations) NURSING FUNDAMENTAL yetty questions
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1 A nurse is assessing for early signs of compartment syndrome for a client who has a short-leg fiberglasscast. Which of the following findings should the nurse expect?
A. Capillary refill less than 2 seconds
B. Bounding distal pulses
C. Intense pain with movement
D. Erythema of the toes
2 A nurse is monitoring a client who is receiving 2 units packed RBCs. Which of the following
manifestations indicates a hemolytic transfusion reaction?
A. Chills ? (think fever, you get cold when your body is hot)
B. Hypertension
C. Bradycardia
D. Back pain
3 A nurse is caring for a client who had a total hip arthroplasty. Which of the following actions should the
nurse take to prevent hip dislocation?
A. Remove the wedge device when turning
B. Place two bed pillows between the legs when in bed
C. Encourage the client to lean forward when attempting to stand
D. Elevate the knees higher than the hips when sitting
4 A nurse is assessing a client who is preoperative and reports an allergy to bananas. The nurse should
recognize that the client is at risk for an allergic cross-reactivity to which of the following substances
A. Povidone-iodine
B. Adhesive tape
C. Latex
D. Anesthetics
5 A nurse is teaching a client about the use of an incentive spirometer. Which of the following
instructions should the nurse include in the teaching?
A. Place hands on the upper abdomen during inhalation.
B. Position the mouthpiece 2.5 cm (1 in) from the mouth
C. Exhale slowly through pursed lips
D. Hold breaths about 3 to 5 seconds before exhaling
,6 A nurse is caring for a client who arrives at the emergency department and reports vomiting and
diarrhea for the past 3 days. The client’s serum potassium level is 2.8mEq/L. Which of the following
interventions should the nurse implement first? Priority question remember, what can I do first, you can
start a K+ drip without knowing how their heart is affected.
A. Check the clients hand grasps
B. Administer an IV potassium drip
C. Listen to the client’s bowel sounds
D. Initiate cardiac monitoring for the clients This is a priority!!!
7 A nurse is preparing to administer peritoneal dialysis to a client. Which of the following actions should
the nurse take?
A. Chill the dialysate before administration
B. Hang the drainage bag below the client’s abdomen
C. Place the client in high-Fowlers position
D. Use clean technique to access the catheter
8 A nurse is preforming a cranial nerve assessment on a client following a head injury. Which of the
following findings should the nurse expect if the client has impaired function of the vestibulocochlear
nerve (cranial nerve VIII)?
A. Inability to smell
B. loss of peripheral vision
C. Disequilibrium with movement
D. Deviation of the tongue from midline
9 A nurse is planning care for a client who is one day postoperative Following an open
cholecystectomy. Which of the following interventions should the nurse include in the plan of care?
A. Place pillows under the clients knees
B. Avoid use of anticoagulants
C. Discourage leg exercises while in bed
D. apply compression stockings to the lower extremities
10 A nurse is caring for a male client who has an exacerbation of heart failure. Which of the following
prescriptions should the nurse expect to receive from the provider? (click on the “exhibit” button for
additional information about the client. There are 3 tabs that contain separate categories of data.)
A. Atropine 1mg IV bolus every 5 min up to 3 mg ?
B. Adenosine 6mg rapid IV bolus now
C. Verapamil 80 mg PO TID
D. Furosemide 40 mg IV bolus every 6 hr.
, 11 A nurse is providing a discharge teaching to a client following a modified left radical mastectomy with
breast expander. Which of the following statements by the client indicates an understanding of the
teaching?
A. “I will keep my left arm flexed at the elbow as much as possible” ?
B. “ I should expect less than 25 mL of secretions per day in the drainage devices”
C. “I will perform strength building arm exercises using a 15 pound weight”
D. “ I will have to wait 2 months before additional saltine can be added to my breast expander”
12 A nurse is teaching a client about using a metered-dose rescue inhaler. Which of the following
statements should the nurse include I the first teaching?
A. “Do not shake your inhaler before use”
B. “Exhale Fully before bringing the inhaler to your lips “
C. “Use Peroxide to clean the mouthpiece of your inhaler”
D. “Depress the canister after you inhale”
13 A nurse is caring for a client who has been receiving total parental nutrition (TPN) for 1 week. For
which of the following findings should the nurse notify the provider?
A. Calcium level 11.5 mg/dL
B. Serum albumin level 3.9g/dl
C. Output 200 mL more than intake over the past 12 hr.
D. Fasting blood glucose level 105 mg/dL
14 A nurse is preparing to discharge a client who has a halo device and is reviewing new
prescriptions from the provider. The nurse should clarify which of the following prescriptions with
the provider?
A. Take tub baths instead of showers
B. May place a small pillow under the head while sleeping
C. May operate a motor vehicle when no longer taking analgesics correct
D. Increase intake of fiber-rich foods
15 A nurse is setting up a sterile field before preforming a dressing change on a client who is
postoperative. Which of the following actions should the nurse plan to take to maintain the sterile
field? (Select all that apply) a,b,c
A. Grasp 2.5 cm (1 in) of the outer edge to open the surgical wrap
B. Open the first flap of the sterile package toward the nurse’s body
C. Place a surgical pack with a sterile drape on the work surface
D. Select a work surface at the nurse’s waist level this is wrong
E. Apply sterile gloves before opening the pack
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