a nurse is caring for a client who has bilateral c
a nurse is caring for a patient who is on a pca pu
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West Coast University
NURS 100
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NURS 100 fundamental final
1. - ANS-
2. 5 clinical manifestations at the end of life and 3 nursing interventions - ANS-Cheyne
stokes (death rattle)
3. Tacky> brady, hypotension, diminshed reflexes, mottling skin, decreased urine output,
incontinence, muscle loss, anxiety and life review....
4. Symptom management (pain control), keep clean, elevate HOB, and collaborative care
5. 5 Stages of grief - ANS-DABDA
6. Denial, anger, bargaining, depression and acceptance
7. A client who reports shortness of breath requests her nurse's help in changing positions.
After repositioning the client, which of the following actions should the nurse take next? -
ANS-Observe the rate, depth, and character of the client's respirations.
8. a home health nurse is planning to provide health promotion activities for a group of
clients in the community. Which of the following activities is an example of the nurse
promoting primary prevention? - ANS-Educating clients about the recommended
immunization schedule for adults.
9. A nurse administered morphine to a patient. When she came back to assess the patient,
the patient's respiratory rate was 6. What medication should the nurse adminster? -
ANS-Furosemide
10. A nurse is caring for a client who has bilateral casts on her hands. Which of the following
actions should the nurse take when assisting the client with feeding? - ANS-Sit at the
bedside while feeding the client.
11. A nurse is caring for a client who, while sitting in a chair, starts to experience a seizure.
Which of the following actions should the nurse take? - ANS-lower the client to the floor
and place a pad under the client's head.
12. A nurse is caring for a patient post op abdominal surgery and the client tells the nurse he
felt a pop early and his incision split open. What should the nurse do first? - ANS-apply a
moist sterile gauze to the site
13. A nurse is caring for a patient who has just been diagnosed with terminal cancer. He
states, "I don't care what the doctors say I am not going to die". What stage of grief is the
patient experiencing? - ANS-Denial
14. A nurse is caring for a patient who is on a PCA pump. Which education should the nurse
provide to the patient? (Select all that apply). - ANS-Only you are allowed to push the
pump for more medication.
15. The pump will provide a constant plasma level.
16. You will still be administered medication even if you do not push the button.
17. A nurse is consulting with the dietitian about a patient with a pressure ulcer. What should
the patient's diet be high in? - ANS-Protein
18. A nurse is educating a patient who recently started taking aspirin. Which of the following
education is correct? - ANS-Monitor for tinnitus
, 19. A nurse is going to administer a tuberculin test intradermally. What angle should the
nurse insert the needle? - ANS-15 degrees
20. A nurse is measuring a patient's temperature. The nurse witnessed the client drink ice
water. What should the nurse's action be next? - ANS-Come back in 20-30 minutes to
check the temperture
21. A nurse is planning care for a client who has a single-lumen nasogastric (NG) tube for
gastric decompression. Which of the following actions should the nurse include in the
plan of care?(select all that apply.) - ANS-Provide oral hygiene frequently
22. measure the drainage from the NG tube every shift
23. Secure the NG tube to the client's gown
24. A nurse is planning to perform passive range-of-motion exercises for a client. Which of
the following actions should the nurse take? - ANS-repeat each joint motion five times
during each session.
25. a nurse is preparing to administer a cleansing enema to a client. Which of the following
actions should the nurse plan to take? - ANS-Position the client on his left side
26. A nurse is preparing to administer Motrin 500mg PO every 8 hours. The amount avilable
is 250mg tablets. How many tablets should the nurse adminster with each dose? (round
your answer to the nearest whole number). - ANS-2 tablets
27. A nurse is providing an in-service on fire safety. Which on the following is in the correct
order? - ANS-Rescue, alarm, contain, extinguish (RACE)
28. A nurse is providing discharge teaching to a client who is recovering from lung cancer.
The provider instructed the client that he could resume lower-intensity activities of daily
living. Which of the following activities should the nurse recommend to the client? -
ANS-washing dishes
29. A nurse is taking care of a patient who is being admitted for possible dehydration. His lab
values read BUN 25 and creatine 1.9. Which lab value would be order to confirm
dehydration? - ANS-Urine specific gravity
30. A nurse is taking care of a patient who is experiencing a breathing pattern characterized
by alternating periods of apnea and hyperventilation. The nurse should document this
as? - ANS-Cheyene-Stokes respirations
31. A nurse is taking care of a patient who is receiving palliative care. Which statement
made to the nurse by the client would indicate an understanding of the treatment? -
ANS-I am hopeful this will help with my discomfort
32. A nurse is teaching a client how to self-administer insulin. Which of the following actions
should the nurse take to evaluate the clients understanding of the process within the
psychomotor domain of learning? - ANS-Have the client demonstrates the procedure
33. A nurse notices a patient having a seizure. Which of the following should the nurse do?
(Select all that apply). - ANS-Turn the patient to the side.Remove objects from around
the patient.Place pillow under patient's head
34. A patient has been sent home with a terminal diagnosis, but denies hospice care. What
should the nurse do first? - ANS-Assess the patient's understanding of hospice care
35. A patient has been sent home with a terminal diagnosis, but denies hospice care. What
should the nurse do first? - ANS-Assess the patient's understanding of hospice care.
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