Nursing Fundamentals Questions 6.

A 49-year-old client with acute respiratory distress watches everything the staff does and demands full explanations for all procedures and medications. Which of the following actions would best indicate that the client has achieved an increased level of psychological comfort? a. Making decreased eye contact b. Asking to see family members c. Joking about the present condition d. Sleeping undisturbed for 3 hours 7. A hospitalized client who has a living will is being fed through a nasogastric (NG) tube. During a bolus feeding, the client vomits and begins choking. Which of the following actions is most appropriate for the nurse to take? a. Clear the client's airway. b. Make the client comfortable. c. Start cardiopulmonary resuscitation. d. Stop the feeding and remove the NG tube. 8. The nurse is caring for a geriatric client with a pressure ulcer on the sacrum. When teaching the client about fundamentals in nursing on dietary intake, which foods should the nurse plan to emphasize? a. Legumes and cheese b. Whole grain products c. Fruits and vegetables d. Lean meats and low-fat milk 9. A client with chronic renal failure is admitted with a heart rate of 122 beats/minute, a respiratory rate of 32 breaths/minute, a blood pressure of 190/110 mm Hg, neck vein distention, and bibasilar crackles. Which nursing diagnosis takes highest priority for this client? a. Fear b. Urinary retention c. Excessive fluid volume d. Self-care deficient: Toileting 10. A client's blood test results are as follows: white blood cell (WBC) count is 1,000/l; hemoglobin (Hb) level, 14 g/dl; hematocrit (HCT), 42%. Which of the following goals would be most important for this client? a. Promote fluid balance b. Prevent infection. c. Promote rest. d. Prevent injury.

1. A facility has a system for transcribing medication orders to a Kardex as well as a computerized medication administration record (MAR). A physician writes the following order for a client: "Prednisone 5 mg P.O. daily for 3 days." The order is correctly transcribed on the Kardex. However, the nurse who transcribes the order onto the MAR neglects to place the limitation of 3 days on the prescription. On the 4th day after the order was instituted, a nurse administers prednisone 5 mg P.O. During an audit of the chart, the error is identified. The person most responsible for the error is the: a. nurse who transcribed the order incorrectly on the MAR b. nurse who administered the erroneous dose. c. pharmacist who filled the order and provided the erroneous dose. d. facility because of its policy on transcription of medications. 2. To evaluate a client's chief complaint, the nurse performs deep palpation. The purpose of deep palpation is to assess which of the following? a. Skin turgor b. Hydration c. Organs d. Temperature 3. One of the nursing fundamentals questions is about giving an I.M. injection, the nurse should insert the needle into the muscle at an angle of: a. 15 degrees. b. 30 degrees. c. 45 degrees. d. 90 degrees. 4. A client, age 43, has no family history of breast cancer or other risk factors for this disease. The nurse should instruct her to have a mammogram how often a. Once, to establish a baseline b. Once per year c. Every 2 years d. Twice per year 5. When prioritizing a client's plan of care based on Maslow's hierarchy of needs, the nurse's first priority would be: a. allowing the family to see a newly admitted client. b. ambulating the client in the hallway. c. administering pain medication d. placing wrist restraints on the client.

Answers and Rationale 1) B - The nurse administering the dose should have compared the MAR with the Kardex and noted the discrepancy. The transcribing nurse and pharmacist aren't void of responsibility; however, the nurse administering the dose is most responsible. The facility's policy does provide for a system of checks and balances. Therefore, the facility isn't responsible for the error. 2) C - The purpose of deep palpation, in which the nurse indents the client's skin approximately 1" (3.8 cm), is to assess underlying organs and structures, such as the kidneys and spleen. Skin turgor, hydration, and temperature can be assessed by using light touch or light palpation 3) D Nursing Fundamentals Questions Rationale: When giving an I.M. injection, the nurse inserts the needle into the muscle at a 90-degree angle, using a quick, dartlike motion. A 15-degree angle is appropriate when administering an intradermal injection. A 30-degree angle isn't used for any type of injection. A 45- or 90-degree angle can be used when giving a subcutaneous injection 4) C - A client age 40 to 49 with no family history of breast cancer or other risk factors for this disease should have a mammogram every 2 years. After age 50, the client should have a mammogram every year 5) C - In Maslow's hierarchy of needs, pain relief is on the first layer. Activity (option B) is on the second layer. Safety (option D) is on the third layer. Love and belonging (option A) are on the fourth layer. 6) D - Sleeping undisturbed for a period of time would indicate that the client feels more relaxed, comfortable, and trusting and is less anxious. Decreasing eye contact, asking to see family, and joking may also indicate that the client is more relaxed. However, these also could be diversions. 7) A - A living will states that no life-saving measures are to be used in terminal conditions. There is no indication that the client is terminally ill. Furthermore, a living will doesn't apply to nonterminal events such as choking on an enteral feeding device. The nurse should clear the client's airway. Making the client comfortable ignores the life-threatening event. Cardiopulmonary resuscitation isn't indicated, and removing the NG tube would exacerbate the situation 8) D - Although the client should eat a balanced diet with foods from all food groups, the diet should emphasize foods that supply complete protein, such as lean meats and low-fat milk, because protein helps build and repair body tissue, which promotes healing. Fundamentals in nursing teaches that legumes provide incomplete protein. Cheese contains complete protein, but also fat, which should be limited to 30% or less of caloric intake. Whole grain products supply incomplete proteins and carbohydrates. Fruits and vegetables provide mainly carbohydrates. 9) C - A client with renal failure can't eliminate sufficient fluid,

increasing the risk of fluid overload and consequent respiratory and electrolyte problems. This client has signs of excessive fluid volume and is acutely ill. Fear and a toileting self-care deficit may be problems, but they take lower priority because they aren't life-threatening. Urinary retention may cause renal failure but is a less urgent concern than fluid imbalance. 10) B - The client is at risk for infection because the WBC count is dangerously low. Hb level and HCT are within normal limits; therefore, fluid balance, rest, and prevention of injury are inappropriate.