Pn fundamentals 2023
Total Questions : 54
Showing 25 questions, Sign in for moreA nurse is collecting data from a client who has a BMI of 29. The nurse should document that the client is in which of the following weight categories?
Explanation
A. A BMI of 25–29.9 is categorized as "overweight." This indicates that the client is above the ideal weight range but has not reached the threshold for obesity.
B. Underweight is defined as a BMI below 18.5, so this option does not apply to a BMI of 29.
C. Ideal body weight is generally associated with a BMI between 18.5 and 24.9, which does not include a BMI of 29.
D. Obesity is defined as a BMI of 30 or above. Therefore, a BMI of 29 does not meet the criteria for this classification.
A nurse is assisting with the care of a client who is experiencing dysphagia following a recent stroke. The nurse should initiate a referral to which of the following interprofessional team members?
Explanation
A. Occupational therapists help clients with daily living activities but are not primarily involved in managing dysphagia.
B. A registered dietitian can provide guidance on nutritional needs but does not typically manage the mechanics of swallowing.
C. A respiratory therapist focuses on respiratory issues, not on swallowing difficulties.
D. A speech-language pathologist is specifically trained to evaluate and treat swallowing disorders (dysphagia), which makes them the appropriate specialist for this referral.
A nurse is reinforcing teaching about beginning an exercise program with an older adult client who is at risk for osteoporosis. Which of the following activities should the nurse recommend?
Explanation
A. Passive range-of-motion exercises do not provide sufficient bone-strengthening benefits for osteoporosis prevention.
B. Bowling, while weight-bearing, may involve sudden twists and movements that could risk injury for an older adult with osteoporosis.
C. Walking is a weight-bearing exercise that is low-impact, which helps improve bone density and is generally safe and recommended for osteoporosis prevention.
D. Jogging could be too high-impact and increase the risk of fractures in clients at risk for osteoporosis.
A nurse is caring for a client who is postpartum. Which of the following documentations should the nurse include in the client's health record?
Explanation
A. Documenting self-care instruction is vague and lacks specificity on the client's physical status postpartum.
B. Documenting the status of the episiotomy provides essential information regarding healing and recovery, a priority in postpartum care.
C. Tracking fluid intake may be relevant for hydration status but is less critical than documenting the episiotomy for postpartum assessment.
D. Although an elevated temperature may indicate infection, it would be secondary to recording the condition of an episiotomy, which directly relates to postpartum recovery and potential complications.
A nurse is preparing to obtain a capillary blood specimen from a client. Which of the following actions should the nurse take? (Select all that apply.)
Explanation
A. Squeezing the client’s finger should be avoided as it can cause hemolysis and affect the accuracy of the blood sample.
B. Pricking the side of the client’s finger is recommended as it tends to be less painful and reduces tissue damage.
C. Elevating the hand above the heart level could reduce blood flow, making it more difficult to obtain a sample.
D. An alcohol swab, not iodine, is typically used to cleanse the site for a capillary blood draw, as iodine can interfere with certain lab results.
E. Applying clean gloves is a standard precaution to prevent contamination and protect both the nurse and the client.
A nurse on a medical-surgical unit is caring for a postoperative client who reports difficulty sleeping due to noise. Which of the following interventions is appropriate for the nurse to implement?
Explanation
A. Turning off bedside alarms is unsafe, as they are crucial for monitoring the client’s condition.
B. Avoiding the client’s room entirely could lead to missed opportunities to assess and address their needs.
C. Conducting staff communications away from the client's room can reduce noise and create a more restful environment.
D. Turning on the TV may add to the noise and is unlikely to promote restful sleep.
A nurse is reinforcing teaching with a client who has crutches regarding the use of the three-point gait. Which of the following instructions should the nurse include?
Explanation
A. In the three-point gait, weight is borne on the unaffected leg while the client moves the crutches and the affected leg together.
B. Crutches should be positioned a few inches in front and to the side of each foot to maintain balance and prevent falls.
C. Holding the arms straight can cause strain; a slight bend at the elbows is ideal.
D. Crutches should not be at the axillae level to prevent nerve damage. There should be a 1–2 inch gap below the armpit.
A nurse is collecting data from a client who is immobile and has a potential deep-vein thrombosis. Which of the following findings should the nurse report to the provider?
Explanation
A. Calf swelling is a common sign of deep-vein thrombosis (DVT) and should be reported as it could indicate a blood clot, which may lead to serious complications if not addressed.
B. Bradycardia is unrelated to DVT and may be due to other underlying conditions.
C. Clammy skin could indicate shock or other systemic issues but is not directly associated with DVT.
D. Tortuous veins are generally a sign of chronic venous insufficiency, not an acute finding indicative of DVT.
A nurse is observing an assistive personnel (AP) provide postmortem care for a client prior to visitation by their loved ones. Which of the following actions by the AP requires intervention by the nurse?
Explanation
A. Gathering personal belongings is appropriate for safekeeping or distribution to family members.
B. Closing the client’s eyes is part of respectful postmortem care.
C. Washing the client’s face is a standard part of preparing the body for viewing.
D. Dentures are typically left in place to maintain facial structure and present a natural appearance for family visitation.
A nurse is assisting with the care of a client who has cancer that has metastasized. The client has decided to discontinue chemotherapy treatment. Which of the following responses should the nurse make?
Explanation
A. Telling the client their quality of life will be compromised may feel judgmental and does not respect their autonomy.
B. This response encourages the client to consider how to communicate their decision with family and shows empathy and support.
C. Saying "everything will work out" is dismissive and minimizes the client’s difficult decision.
D. "We should talk about your decision later" disregards the client’s immediate emotional needs.
A nurse is preparing to reinforce teaching with a client who has expressive aphasia. Which of the following actions should the nurse plan to take?
Explanation
A. Although the client has difficulty with speech, they can still understand and may want to respond nonverbally.
B. A communication board can help clients with expressive aphasia convey their needs and participate in teaching.
C. Speaking in a loud voice does not aid understanding and may be perceived as disrespectful.
D. Using facial gestures can enhance communication by providing additional visual cues.
A nurse is inserting an indwelling urinary catheter for a male client. After inserting the catheter 15 cm (6 in), the nurse feels resistance and no urine flows through the catheter. Which of the following actions should the nurse take?
Explanation
A. Lidocaine gel should be applied before insertion for comfort but is not appropriate at this stage.
B. Gently twisting the catheter may help it navigate past the resistance, often caused by the prostatic urethra.
C. Inflating the balloon before confirming correct placement can cause urethral trauma.
D. Keeping the penis elevated at a 90° angle helps straighten the urethra, which aids insertion.
A nurse is caring for a client who has a new prescription for a belt restraint. Which of the following actions should the nurse take?
Explanation
A. Applying the restraint over the client’s gown protects the skin and ensures comfort.
B. Restraints should never be tied to the side rail as it could lead to injury if the bed is adjusted; they should be tied to a stable part of the bed frame.
C. Skin integrity should be checked more frequently than every 4 hours to prevent injury.
D. Typically, two fingers, not four, should fit between the restraint and the client’s body to ensure it’s secure but not too tight.
A nurse is preparing to administer medications to a client. Which of the following pieces of information should the nurse use as a client identifier?
Explanation
A. A photograph can be used as part of positive patient identification, especially if other identifiers (like name and birthdate) are also confirmed.
B. Medical diagnosis is not unique to a client and cannot confirm identity.
C. Age alone is not sufficient for positive identification.
D. Room numbers can change and should never be used as identifiers.
A nurse is caring for an adult client who has a developmental disability. The client requires an emergency appendectomy, and the staff cannot reach the appointed guardian. Which of the following is an appropriate action for the nurse to take?
Explanation
A. Postponing the procedure could put the client’s health at risk.
B. If the client cannot provide informed consent due to a developmental disability, they are not considered able to consent independently.
C. The provider does not sign the consent form on behalf of the client in this situation; rather, implied consent is used in emergencies.
D. In an emergency situation where delaying treatment could harm the client, implied consent allows for immediate life-saving procedures without waiting for guardian consent.
A nurse is reinforcing teaching with a client about advance directives. Which of the following client statements indicates an understanding of the teaching?
Explanation
A. While a witness may be required, it does not have to be a family member and may vary by state law.
B. Advance directives specify health care preferences, not organ donation, which usually requires a separate directive.
C. Naming a family member, like a sibling, as a designee in a durable power of attorney for health care is appropriate and is part of ensuring that health care decisions align with the client’s wishes if they become unable to communicate.
D. Advance directives do not require an attorney’s approval to be valid; they are enforced based on the client’s wishes as documented.
A nurse is caring for a client who refuses their morning dose of antihypertensive medication. The client tells the nurse. "I'm not going to take this medication because it makes me sick and dizzy." Which of the following actions should the nurse take first?
Explanation
A. Documentation is important but should occur after addressing the client’s concerns.
B. Returning the medication is appropriate if the client ultimately refuses it, but initial discussion is needed first.
C. Informing the client of the potential consequences of refusing their medication respects their autonomy while ensuring they understand how it may impact their health. This is the first step to address concerns and provide education.
D. Notifying the provider is necessary if the client continues to refuse after education, as the provider may need to adjust the prescription.
A nurse is coordinating care of a group of clients with an assistive personnel (AP). Which of the following tasks should the nurse assign to the AP?
Explanation
A. Measuring intake and output is within the scope of an AP and appropriate for delegation.
B. Pain assessment requires clinical judgment and should be performed by a licensed nurse.
C. Teaching or reinforcing patient education should be conducted by the nurse, as it involves ensuring proper technique and understanding.
D. Checking an IV site for complications requires assessment skills, which should be completed by the nurse.
A nurse is assisting with feeding a client who has had a stroke. Which of the following findings should the nurse identify as a manifestation of dysphagia?
Explanation
A. Rapid chewing is not specific to dysphagia.
B. A garbled or "wet" voice is often a sign of dysphagia, as it can indicate difficulty with swallowing and risk for aspiration.
C. Sneezing is not typically associated with swallowing difficulties.
D. Increased hunger is unrelated to dysphagia and does not indicate difficulty swallowing.
A nurse is reinforcing discharge teaching with a male client who has an indwelling urinary catheter. Which of the following statements by the client indicates an understanding of the teaching?
Explanation
A. Applying antiseptic ointment is generally not recommended as it can cause irritation and may introduce bacteria.
B. Keeping the drainage bag below waist level helps maintain proper urine flow and reduces the risk of backflow, which can cause infection.
C. The drainage bag should be emptied when it is about half full, not only once a day, to prevent backflow and infection.
D. Clamping the tube is not advised as it could lead to urine retention and increase the risk of infection.
A nurse is providing end-of-life care to a client who is experiencing dyspnea. Which of the following actions should the nurse take?
Explanation
A. Oral care should be provided more frequently, especially for clients with dyspnea, to maintain comfort and hydration.
B. A fan helps circulate air, which can relieve dyspnea by promoting a feeling of airflow and ease of breathing.
C. Repositioning should occur more frequently than every 4 hours, especially for comfort and skin integrity.
D. Elevating the head of the bed, rather than keeping it flat, is recommended to alleviate dyspnea.
A nurse in a provider's office is reviewing data from a client's medical record. Which of the following findings should the nurse identify as a risk factor for cardiovascular disease?
Explanation
A. Orthostatic hypotension is not a direct risk factor for cardiovascular disease, though it can be related to other health issues.
B. Type 1 diabetes mellitus increases the risk for cardiovascular disease due to chronic hyperglycemia, which can damage blood vessels over time.
C. Osteoporosis is a risk for bone health but is not a cardiovascular risk factor.
D. A BMI of 24 is within the normal range and does not pose a cardiovascular risk.
A nurse is caring for a client who has a terminal illness. The client asks what type of care will be provided as death approaches. Which of the following statements should the nurse make first?
Explanation
A. Asking the client about their expectations encourages them to share their feelings and desires regarding end-of-life care, which establishes a foundation for personalized care planning.
B. Offering spiritual support is important but should come after understanding the client’s specific expectations.
C. Family visitation is a supportive option, but understanding the client’s overall desires is more essential.
D. Nonpharmacological pain management is beneficial, but it should be discussed in the context of the client's expressed goals and preferences.
A nurse is reinforcing teaching with a client about using guided imagery to manage chronic pain. Which of the following statements by the client Indicates an understanding of this technique?
Explanation
A. Focused breathing is part of relaxation techniques but is not the same as guided imagery.
B. Noticing muscle tension is part of progressive muscle relaxation, not guided imagery.
C. Guided imagery involves visualizing a pleasant or calming scene (such as a farm) to distract from pain and promote relaxation.
D. Listening to music can be helpful for relaxation but is a separate strategy from guided imagery.
A nurse is caring for a client who requires a sterile dressing change. The nurse should recognize that the surgical field has been contaminated if which of the following actions occur?
Explanation
A. Holding the sterile solution bottle over the field is acceptable as long as it is not placed on the field.
B. Placing unnecessary sterile items does not contaminate the field, though it may clutter the workspace.
C. Allowing sterile forceps to rest in a container of sterile water compromises the sterility of the field, as the water can act as a medium for contamination.
D. The handle of sterile scissors resting close to the field edge is acceptable if it is not in contact with the non-sterile area.
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