Download NURS 230 Fundamentals FINAL EXAM 2025 GRADED A+ WITH ANSWERS 100% ACCURATE and more Exams Nursing in PDF only on Docsity!
NURS 230 Fundamentals FINAL EXAM 2025
GRADED A+ WITH ANSWERS 100%
ACCURATE
A nurse is preparing to insert an IV catheter into a client's arm prior to initiating IV fluid therapy. Which of the following interventions should the nurse implement to prevent infection? a) Thread the IV catheter so that the hub rests at the insertion site b) Shave excess hair from around the insertion site c) Cleanse the site with hydrogen peroxide before IV catheter insertion d) Palpate the site carefully just before inserting the IV catheter A Inserting the catheter up to the hub reduces the risk of contaminating along the length of the catheter A nurse is caring for a postoperative adult client who refuses to use an incentive spirometer following major abdominal surgery. Which of the following is the nurse's priority action? a) Request that a respiratory therapist discuss the technique for incentive spirometry b) Administer a pain medication to the client c) Chart the client's refusal to participate in health restorative activities d) Determine the reasons why the client is refusing the use the incentive spirometer D
A nurse is preparing to administer meperidine (Demerol) 80 mg IM from a 100 mg prefilled syringe. After the injection, which of the following is an appropriate action by the nurse? a) Return the unused portion to the pharmacy b) Have another nurse witness the disposal of the excess medication c) Place the syringe with the unused portion in a locked medication drawer d) Discard the unused medication in the sharps container B meperidine is a controlled substance A nurse is caring for a client who has tuberculosis. Which of the following actions should the nurse take? SATA a) Place the client in a negative pressure room b) wear gloves when assisting the client with oral care c) limit each visitor to 2 hr increments d) wear a surgical mask when providing care e) Use antimicrobial sanitizer for hand hygiene A, B, E A charge nurse is discussing the responsibility of nurses carig for clients who have C. difficile. Which of the following information should the nurse include in the teaching? a) Assign the client to a room with a negative air-flow system b) Use alcohol-based hand sanitizer when leaving the clients room
A charge nurse is observing a newly hired nurse prepare a sterile field. Which of the following indicates to the charge nurse that the sterile field is contaminated? a) Outer edges of the sterile field is touching a bottle b) first fold is opened away from the body c) sterile objects are held above the waist d) sterile field is opened on a wet surface D Opening a sterile field on a wet surface contaminates it because capillary action can wick bacteria through the dressing A nurse is caring for a client who has dementia. Which of the following interventions should the nurse take to minimize the risk for injury for this client? a) use a bed exit alarm system b) raise 4 side rails while client is in bed c) apply one soft wrist restraint d) dim the lights in the client's room A We have an expert-written solution to this problem! A nurse is implementing a plan of care for a client who is at risk for falls. Which of the following is an appropriate nursing action?
a) implement a regular toileting schedule b) encourage the client to wear athletic socks when ambulating c) place all 4 bed rails in the upright position c) require a family member to remain at the bedside A The nurse should toilet every 1 to 3 hours to reduce the risk of falls due to the client ambulating to the bathroom without assistance A nurse is completing an admission assessment of an older adult client. Which of the following findings is a potential indication of abuse? a) loss of skin turgor on the back of the hands b) varicosities on lower extremities c) thickened discolored nail with ridges d) presence of bruises on the arm in various stages of healing D A nurse is educating a family member of a client who is immobile about how to prevent back injury associated with moving the client up in bed. Which of the following statements by the family member should indicate to the nurse that he understands the teaching? a) "I will relax my abdominal muscles when preparing to move her" b) "I will keep my knees straight and my feet together" c) I will move back from the bed and bend at the waist" d) I will leverage my weight against my wife and shift as I move her"
b) touch her chin to chest c) touch her ear to shoulder d) move her head from side to side D A nurse in a long-term care facility is planning to perform hygiene care for a new resident. Which of the following assessment questions is the nurse's priority before beginning this procedure? a) "When do you usually bathe, in the morning or the evening?" b) "Do you prefer a bath or shower?" c) "At what temperature do you prefer your bath water?" d) Are you able to help with your hygiene care?" D The greatest risk to the client's safety is an injury from an overestimation of the client's ability to help with hygiene care. A nurse is caring for a client following an acute myocardial infarction. The client is concerned that providing self-care will be difficult due to extreme fatigue. Which of the following strategies should the nurse implement to promote the client's independence? a) request an occupational therapy consult to determine the need for assistive devices b) assign assistive personnel to perform self-care tasks for client c) instruct the client to focus on gradually resuming self-care tasks d) ask the client if a family member is available to assist with his care C
By gradually increasing performance of tasks, the client can feel a sense of accomplishment before taking on additional tasks. A nurse is reviewing the medical records of a client who has a pressure ulcer. Which of the following is an expected finding? a) serum albumin level of 3 g/dL b) HDL level of 90 mg/dL c) Norton scale score of 18 d) Braden scale score of 20 A Serum albumin level below 3 g/dL indicates protein deficiency, putting the client at risk for pressure ulcer formation and poor wound healing A nurse is caring for a client who needs a 24-hr urine collection initiated. Which of the following client statements indicates an understanding of the procedure? a) "I had a bowel movement, but I was able to save the urine" b) "I have a specimen in the bathroom from about 30 minutes ago" c) "I flushed what I urinated at 7 am and have saved the rest since" d) "I drink a lot, so I will fill up the bottle and complete the test quickly" C
a) speak loudly with the mouth close to the clients ear b) rephrase rather than repeat misunderstood information c) ask a family member about the clients health history d) use a high tone of voice instead of a low tone of voice B A nurse is performing a Romberg's test during the physical assessment of the client. Which of the following should the nurse use? a) touch the face with a cotton ball b) apply a vibrating tuning fork to the clients forehead c) have the client stand with arms at side and feet together d) perform direct percussion over the area of the kidneys C Romberg's test assesses for alterations in balance therefore, the nurse should observe for swaying and a loss of balance A nurse planning care of an adolescent who is postoperative following a lumbar laminectomy. Which of the following interventions should the nurse include in the plan of care? a) limit the adolescent's visitors b) select the adolescent's food choices c)allow the adolescent to make decisions regarding the daily routine d) encourage the adolescent's parents to assist with personal hygiene C
A nurse is caring for a client who has taken in 2,600 mL of fluids in 24 hr. Which of the following is an expected output for the client? a) 1,800 mL b) 2,100 mL c) 2,500 mL d) 3,200 mL C The client's output should approximate the daily fluid intake A nurse is reinforcing teaching regarding the use of a cane to a client who has left-leg weakness. Which of the following should the nurse include in the teaching? a) use the cane on the weak side of the body b) advance the cane and the atrong leg simultaneously c) maintain two points of support on the floor d) advance the cane 30 to 45 cm (12-18 in) with each step C Which of the following should indicate to a nurse the need to suction a client's tracheostomy? a) irritability b) hypotension
A nurse is caring for a client in the immediate postoperative period. The nurse should recognize that which of the following positions moximizes the effectiveness of incentive spirometry? a) side-lying b) supine c) semi-fowler's d) trandelenburg C HOB raised approximately 30 degrees allows for maximum expansion of the lungs Which of the following precautions is important to take when a nurse is caring for a client who has diarrhea due to Shingella? a) have the client wear a mask when receiving visitors b) wash hands before and after client contact c) assign the client to a room with negative pressure air flow d) instruct all visitors to limit time with the client B A nurse is reviewing practice guidelines with a group of newly licensed nurses. Which of the following interventions falls within the RN scope of practice? a) insert an implanted port
b) close a laceration with sutures c) place an endotracheal tube d) initiate en enteral feeding through a PEG tube D A nurse is caring for a client receiving fluid through a peripheral IV catheter. Which of the following findings at the IV site should the nurse recognize as infiltration? a) purulent exudate b) warmth c) skin blanching d) bleeding C A nurse is caring for a client with cancer who lives at home with her spouse. The spouse tells the nurse that the client is in pain "all of the time." Which of the following actions is most appropriate for the nurse to take? a) assess the client's vital signs b) assess the spouses understanding of the clients pain c) ask the spouse how he has been managing the client's pain d) ask the client to rate her pain D
c) place a note in the client's chart for the provider to review the order the next day d) contact the pharmacist to determine the frequency of blood glucose checks B A nurse is planning to delegate client care to an assistive personnel. Which of the following factors is most important for the nurse to consider before delegating care? a) the AP's previous trainging b) other tasks assigned to the AP c) the amount of supervision the AP requires d) the facility's jobb description for the AP D A nurse is caring for a client who reports pain. When documenting the quality of the client's pain on an initial pain assessment, the nurse should record which of the following client statements? a) "I am having mild pain" b) "The pain makes me feel nauseous" c) "I notice that the pain gets worse after I eat" d) "The pain is like a dull ache in my stomach" D A nurse in a long-term care facility notes that a client coughs frequently during meals and suspects dysphagia. The nurse should assess the client for which of the following behavioral signs of dysphagia?
a) storing food in the mouth b) sipping warm liquids c) chewing excessively d) refusing soft foods A Clients who have dysphagia tend to have incomplete emptying of the food from their mouth. This can lead to collections of food or "pockets" of food left in the mouth, which they tuck in front of the buccal surfaces of the gums A hospice nurse is providing end-of-life care to a client who has terminal lung cancer. The client states, "I am so tired and afraid of not being able to catch my breath." Which of the following is an appropriate response by the nurse? a) "We should restrict your visitors so that you can get more rest" b) "shortness of breath is temporary and should subside" c) "I will be able to give you more a medication to help your breathing" d) "fatigue is a common experience among hospice clients" C the nurse can administer bronchodilators, inhaled steroids, or opiates to promote comfort and ease breathing, air hunger, and apprehension for clients who are terminally ill and are experiencing shortness of breath A nurse is conducting a respiratory assessment for four clients. Which of the following should the nurse recognize as an abnormal respiratory assessment finding?
d) locks elbows when stepping forward A A nurse is providing discharge teaching for a client who has a new prescription for a home oxygen concentrator. Which of the following instructions should the nurse give to the client and his family? SATA a) Check the cord routinely for frays and tearing b) keep the unit at least 4 feet away from a heat source c) Consider purchasing a generator for power backup d) monitor for signs of hypoxia e) Select clothing and bedding made of synthetic materials A, C, D A nurse is caring for a client who is scheduled to be transferred to a long-term care facility. The client's family questions the nurse about the reasons for the transfer. Which of the following reposnses made by the nurse is apporpriate? a) "The transfer for your family member is being done because it's in his best interest" b) "Have a seat and let me tell you what has happened" c) "Why are you so concerned about the transfer?" d) "I know how you feel. My father had to be sent to a long-term care facility" B A nurse is preparing a change-of-shift report. Which of the following is an appropriate method to communicate continuity of care?
a) critical pathways b) transfer document c) SBAR d) medication administration record (MAR) C A client is receiving continuous tube feeding via NG tube. The client has 3 episodes of vomiting in 12 hr. Which of the following actions should the nurse take? a) flush the tube with 100 mL of water b) dilute the formula with sterile water c) aspirate for residual d) place the client in a supine position C The nurse should aspirate for residual if vomiting occurs, as this can indicate the client is not absorbing the nutrients A nurse is providing teaching to a client who is recieving chemotherapy. Which of the following client statements indicates an understanding of the teaching? a) "I will disinfect my toothbrush weekly" b) "I will eat fresh fruit for breakfast" c) "I can take a plane to visit my grandson" d) "I can shower up to three times a week"
