Chamberlain College of Nursing - NURSING NR 324Fundies B Assess Qs

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1. A nurse is administering IV fluids to a client. When monitoring for adverse effects, which of the following assessments should the nurse identify as the priority? a. Auscultate lung sounds b. Me... asure urine output c. Monitor blood pressure readings d. Rationale: the priority assessment the nurse should make when using the airway, breathing, circulation approach to client care is auscultating lung sounds to monitor for fluid volume excess, a complication of IV therapy. Manifestations of fluid volume excess include crackles in the lungs, dyspnea, and SOB 2. A charge nurse is discussing the responsibility of nurses caring for clients who have C Diff. which of the following info should the nurse include in teaching? a. Assign the client to a room with negative pressure b. Use alcohol bases hand sanitizer c. Clean contaminated surfaces with phenol solution d. Have family members wear gown and gloves when visiting 3. A nurse is giving change of shift report about a client they admitted earlier who has pneumonia. Which of the following info is priority for the nurse to provide? a. Admitting diagnosis b. Breath sounds c. Body temp d. Rationale: ABC approach. 4. A nurse is planning teaching for a group of adolescents who each recently had surgical placement of an ostomy. Which of the following methods should the nurse use as a psychomotor approach to learning? a. Role play b. Group discussion c. Question answer meetings d. Practice session 5. A nurse is caring for a client who reports difficulty falling asleep. Which of the following recommendations should the nurse make? a. Drink a cup of hot cocoa before bed b. Maintain a consistent time to wake up each day c. Exercise 1 hour before bed d. Watch TV before going to bed 6. Nurse is admitting a client who has rubella. Which of the following types of transmission based precautions should the nurse initiate? a. Droplet b. Rationale: droplet precautions include: influenza, rubella, meningococcal pneumonia, and strep pharyngitis c. Airborne: varicella, TB, measles d. Contact: vanco-resistant enterococci VRE, methicillin-resistant staph aureus MRSA, scabies, This study source was downloaded by 100000784424693 from CourseHero.com on 04-01-2021 06:58:55 GMT -05:00 https://www.coursehero.com/file/79271411/Fundies-B-Assess-Qsdocx/ This study resource was shared via CourseHero.com 7. Nurse is caring for a client who recently started using behind the ear hearing aid, which of the following statements identifies as an indication the client understands the use of this assistive device? a. This type of hearing aid does not allow for fine tuning volume b. I shouldn’t have trouble keeping my hearing aid in place during exercise c. I expect to hear a whistling sound when I first insert the hearing aid d. I will be sure to remove my hearing aid before shower 8. Nurse is caring for a client who has an NG tube and is receiving intermittent feedings through an open system. Which of the following should the nurse take first? a. Rinse feeding bag with water between feedings b. Tell the client to keep the head of bed elevated to 30 c. Make sure enteral formula is at room temp 9. A nurse is planning care for a client who has TB. The nurse should use which of the following pieces of personal protective equipment when providing care for the client? a. Gown b. N95 respirator c. Shoe covers 10. Nurse is preparing to administer 0.5 mL of oral single-dose liquid medication to a client. Which of the following actions should the nurse take? a. Gently shake the container of medication prior to administration b. Rationale: should gently shake it to ensure that the medication is mixed 11. A nurse is performing a peripheral vascular assessment for a client. When placing the bell of the stethoscope on the client’s neck, the nurse hears the following sound: a. Narrowed arterial lumen 12. Nurse is caring for a group of clients on a med surg unit. In which of the following situations does the nurse demonstrate the ethical principle of veracity? a. A client who is unaware of her recent diagnosis asks the nurse if she has cancer, and the nurse responds affirmatively b. Rationale: nurse must tell the truth at all times and never deceive others c. Autonomy: a client who has a prescription for NG tube refuses, and nurse complies with the clients wishes (right to refuse) 13. A nurse in a clinic is caring for a middle adult client who states, “the doctor says that since I am at an average risk for colon cancer, I should have routine screening.” Which of the following responses should the nurse take? a. You should have a fecal occult blood test every year b. Rationale: colorectal cancer screening for clients who are average begins at age 50. 14. Nurse is teaching a group of staff nurses about the use of essential oils for aromatherapy. The nurse should include in the teaching that this therapy might be contraindicated for which of the following clients? a. A client who has had a stoma b. A client who has ulcerative colitis c. A client who has asthma [Show More]

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