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Kaplan fundamentals ngn
Total Questions : 29
Showing 25 questions, Sign in for moreThe nurse is caring for a senior adult client with three diagnoses of Parkinson's disease and an exacerbation of COPD. The nurse observes the unlicensed assistant personnel (UAP) providing morning care and obtaining vital signs by using a portable electronic blood pressure cuff and clip-on pulse oximetry sensor.
Nurse's Notes: Vital Sign # 0715: Client sitting up in bed with oxygen 2.1 per nasal cannula (NC) on. Clear pink skin and warm and dry lungs with scattered wheezes throughout. The client complains of shortness of breath and states, "I feel so much better than I did a couple of days ago." Mild tremors were noted. The client states, "My hands shake all the time."
1140: Client is still in bed with oxygen 2.1 per NC on, scattered wheezes throughout, and coarse rhonchi, which are clear with coughing. Cough is productive of yellow phlegm. Skin cool and dry. The client complains of shortness of breath or discomfort and states, "I like to keep it chilly in my room to help me breathe."
1140: The UAP reports to the nurse that the client's SpO2 is decreased.
Q1. After assessing the patient and reviewing the vital signs, which nursing action is appropriate to address the decreased SpO2?
(Select all that apply.)
The nurse instructs the client on the use of an incentive spirometer. Which observation indicates to the nurse that additional teaching is required?
The nurse provides care for a client with a poor appetite. Which action does the nurse take to enhance the client's nutritional intake?
The emergency department (ED) triage nurse receives a report from emergency medical services (EMS) on an older adult client being brought to the ED via EMS. After receiving the report, the nurse reviews the client's electronic medical record (EMR) for history and the most recent medication list.
1635: Most recent entry from a visit to primary care provider 5 days ago. Vital signs were BP 164/90, HR 96, RR 20, T 96.7°F (35.9°C), and SpO2 96% on room air. Past Medical History (PMH) positive for osteoporosis, a history of ovarian cancer treated with a hysterectomy and chemotherapy 16 years ago, hypercholesterolemia, and hypertension being managed with diet and exercise. During this recent visit, the client was started on hydrochlorothiazide (HCTZ) 12.5 mg, 1 tablet PO every AM. No Known Drug Allergies (NKDA). Additional home medications include:
- Atorvastatin 20 mg PO, 1 tablet every PM
- Calcium 1000 mg, 1 tablet PO BID
- multi-vitamin, 1 capsule PO every AM
The nurse obtained the bloodwork, started the IV, and administered morphine IV push.
> Complete the following sentence:
The nurse's highest priority is planning care knowing that the client is at risk for seizures due to ______and _______.
Explanation
The nurse's highest priority is planning care knowing that the client is at risk for seizures due to hydrochlorothiazide (HCTZ) and chemotherapy.
The nurse's highest priority is planning care knowing that the client is at risk for seizures due to the recent initiation of hydrochlorothiazide (HCTZ), which can cause electrolyte imbalances such as hyponatremia, and the history of chemotherapy for ovarian cancer, which may increase the risk of seizure activity.
The emergency department (ED) triage nurse receives a report from emergency medical services (EMS) on an older adult client being brought to the ED via EMS. After receiving the report, the nurse reviews the client's electronic medical record (EMR) for history and the most recent medication list.
The client was transferred to ED Bed 5 via stretcher. The client’s spouse is at the bedside. The client states "I feel so much better now except my wrist. It's really hurting." Advised to assess and then check with ED physician about something for the pain. VS BP 112/68 HR 99 RR 20. T 98.4° F (36.9° C). SpO2 96% on room air. The client is alert and oriented (A&O x 4), pleasant, and cooperative. PERRLA, skin intact with no bruising except for dorsal left forearm and wrist which is ecchymotic and edematous. Radial pulses are strong and equal (+3). Fingers warm with capillary refill - 3 sec. Lungs clear Abdomen soft with bowel sounds x 4 quadrants. Pedal pulse + x 4 and no pedal edema.
The client is being prepped for an open reduction internal fixation of the left wrist on the morning of day 2.
> Which three findings indicate that the client’s hemodynamic status has improved?
The nurse provides care for a client recovering from a motor vehicle crash. For which sign of fluid volume overload does the nurse measure the client's intake and output? (Select all that apply)
The nurse provides care for a client having an incisional biopsy of a skin lesion. Which teaching about the care of the site does the nurse provide to the client?
The nurse provides care for a child with an abdominal wound. The wound edges are approximated. Which does the nurse include when rendering the prescribed wound care to this child? (Select all that apply)
A client recovering from surgery sits in a chair for breakfast. Which action does the nurse take before applying newly prescribed anti-embolism stockings to the client's lower extremities?
A client receives a clear liquid diet. The nurse removes which item from the client's tray? (Select all that apply)
An infant client has a tracheostomy. The nurse prepares to suction the tracheostomy. Which most important principle does the nurse use to plan care?
The nurse omits to document an assessment finding that resulted in a significant client injury. For which legal issue does the nurse need to prepare?
A family member tells the nurse, "I overheard a caregiver threaten my uncle." The family member said the caregiver remarked, "If you don't learn to calm down, I will have to restrain you." Based on this information, which criminal offense does the nurse communicate to the nurse manager?
A client receives a diagnosis of right-sided paralysis. Which action does the nurse take when assisting the client in transferring from the bed to the wheelchair?
The nurse delegated vital signs for a group of patients to the unlicensed assistive personnel (UAP). Which client condition would prohibit having a rectal temperature taken by the UAP?
The nurse evaluates a client's plan of care. The client has an outcome of 'Client will learn self-glucose testing before discharge'. When evidence best allows the nurse to meet the outcome of the plan?
The nurse plans care for a client who reports avoiding people because of having scabies and difficulty walking. Which statement does the nurse document as the client's greatest concern?
A young adult client has a partner and no children. The client has a hysterectomy because of endometrial cancer. The client has an IV and an indwelling urinary catheter. The client is crying asking for their partner. Which action does the nurse take first?
The nurse provides care for a client who is severely malnourished. A central venous access device (CVAD) is placed to administer total parenteral nutrition (TPN). Which laboratory result does the nurse closely monitor?
In which situation is the nurse determined to be negligent?
The nurse provides care for a client diagnosed with pneumonia. The client is unable to expectorate respiratory secretions. The nurse suctions the client's nasopharyngeal airway. When is suctioning technique correct?
While the nurse prepares an injection for a client, the needle cap falls on the floor. Which action indicates that the injection will be sterile?
The nurse provides care for a patient with an infected surgical wound. The nurse assesses the wound and changes the dressing. Which does the nurse include in the documentation? Select all that apply.
The nurse provides care to a toddler-age client and prescribed catheterization to obtain a urine specimen. Which procedure does the nurse implement? (Select all that apply)
A bed-bound chart has a prescription for routine urinalysis. In which way does the nurse obtain the urine sample for the laboratory?
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