FUNDAMENTALS OF NURSING (SAUNDER) CORRECT ANSWERS 1. A client arrives at the surgical unit after nasal surgery.

The client has nasal packing in place. The nurse reviews the physician's orders and anticipates that which of the following client positions would be prescribed to reduce swelling? a. sim's b. Prone c. Supine d. Semi-Fowler's * 2. A client enters the emergency department with a nosebleed. On assessment, the client tells the nurse that the nosebleed just suddenly began. The nurse notes no obvious facial injury. Which of the following would be the initial nursing action? a. Prepare a nasal baloon for insertion b. Insert nasal packing c. Sit the client down, ask the client to lean forward, and apply pressure to the nose for 5 to 10 minutes.* d. Place the client in a semi-fowlers position and apply ice packs to the nose. 3. A nurse is caring for a client who is receiving total parenteral nutrition (TPN) via a central line. Which nursing intervention would specifically provide assessment data related to the most common complication related to TPN? a. weighing the client daily b. Monitoring I&O c. Monitoring the temperature * d. Monitoring the serum blood urea nitrogen (BUN) 4. A nurse has developed a teaching plan for an elderly client with hypertension about the administration of prescribed medications. The initial nursing action would be to do which of the following? a. Assess the client's readiness to learn * b. Find out if anyone lives with the client

c. d. A low-fiber. The nurse prepares to deliver the lunch tray to the client and checks the food tray to be sure that which of the following is true? a. The client needs to be maintained in supine position. * b. A client is being seen in the clinic for sypmtoms of hyperinsulinism. the nurse keeps which of the following in mind? a. high-fat diet b. At least one serving of low-fat milk is served. Sodiums foods are restricted b. A nurse is developing a plan of care for a client with a nasogastric (NG) tube feeding in place. When formulating the plan of care. Full-liquid diet c. All food item are lukewarm in temperature c. A physician has ordered a clear liquid diet for a postoperative client. Large amounts of carbohydrates between low-protein meals d. and carbohydrates at each meal * 8. 7. Small frequent meals with protein. Set priorities for the client d. Limiting food intake to two meals per day c. Low-residue diet d. Low-sodium diet 6.c. Aspiration is a concern with a nasogastric tube feeding. . High-fiber diet* b. A nurse provides information to the client about dietary measures for the condition. Use only one teaching method to prevent confusion 5. The rate of the feeding needs to be increased if the infusion rate falls behind schedule. A female client tells the home health nurse that she has not had a stool since coming home from the hospital after surgery 4 days ago. Which of the following diets would be most appropriate to suggest to the client? a. fat. The NG tube needs to be changed with every other feeding. All food items are liquid at body temperature * d. Which of the following is the most appropriate diet for this client at this time? a.

The home care nurse assesses the client's use of the cane and determines that the cane is sized correctly if which of the following is true? a. 10. Crutches b. The handle of the cane is even with client's waist b. * c. The nurse plans to include which of the following interventions in the plan of care? a. To medicate with antidiarrheal medications everyday. Hold the cane on the affected (weak) side. A quad cane * d. When going down stairs. b. A nurse is instructing a client who has had a stroke how to ambulate with the use of a cane. move the cane and the unaffected (strong) leg down first. The client has right-sided arm and leg weakness. d. Which of the following instructions would the nurse provide to the client? a. To check around the stoma site for skin irritation. A nurse is preparing a plan of care for a client receiving enteral feedings via a gastrotomy tube (G-tube). A walker http://www. * c. d. The client tells the nurse that he is using a cane that was purchased at a local pharmacy. The nurse would suggest that the client use which of the following assistive devices that would provide the best stability for ambulating? a. * c.blogger.9. To provide oral fluids three times per day b. 12. Move the cane forward first along with the unaffected (strong) leg. . A single straight-legged cane c. Hold the cane on the unaffected (strong) side. A nurse is caring for a client with impaired mobility that occurred as a result of a stroke. To use sterile technique when administering the tube feedings. The home care nurse visits a client who has been experiencing increased weakness.gif 11. d. The client's elbow is flexed at a 50 to 75 degree angle when ambulating with the cane. The client's elbow is flexed at a 15 to 30 degree angle when ambulating with the cane. The client's elbow is straight when ambulating with the

Using a Z-tract method for injection. c. Bone marrow biopsy b. A urine output that is pale yellow in color. The RN would intervene if the nurse observed the LPN perform which of the following? a. Schilling test * c. Massaging the injection site well afer injection. Shortness of breath on exertion. The NA tells the nurse that three enemas have been . b. Clotting time 17. Dusky mucous membrane 16. A nurse is caring for a client with a diagnosis of dehydration. A urine specific gravity of 1. The client is receiving intravenous fluids. A client is performing an assessment on a client with a diagnosis of pernicious anemia. Red tongue that is smooth and sore * d.033 * b.13. A registered nurse (RN) has instructed a nursing assistant (NA) to administer soap solution enemas until clear to a client scheduled for a colonoscopy. A clinic nurse is reviewing the record of a client with a suspected diagnosis of pernicious anemia. Dyspnea c. A blood pressure of 120/80 mmHg d. White blood cell differential d. which of the following assessment data would indicate to the nurse that the dehydration is not resolved? a. Which assessment finding would the nurse expect to note in this client? a. Changing the needle after drawing up the dose and before injection. A registered nurse (RN) is supervising a licensed practical nurse (LPN) administer an intramuscular (IM) injection of iron to an assigned client. * 15. Preparing an air lock when drawing up the medication c.8 F 14. d. b. The nurse reviews the physician's orders and anticipates thatr which of the following diagnostic tests will be ordered? a. An oral temperature of 98.

Stop administering the enemas until the physician is notified. c. The nurse is sitting with a nurse employed at a large trauma center who states that the leadership style at the trauma center is task-oriented and directive. Situational c. c. Supply the triage rooms with bottles of sterile water and normal saline. The nurse is describing which of the following leadership styles? a. 20. * 18. Prolonged QT interval * . Wait 30 minutes abd then administer another enema b. A nurse in the emergency room receives a telephone call from emergency medical services and is told that several victims who survived a plane crash will be transported to the hospital. Call the intensive care unit to request that nurses be sent to the emergency room. Administer an oil-retention enema. The nurse caring for a client with hypocalcemia would expect to note which of the following changes on the electrocardiogram(ECG)? a. The nurse is told that several victims are suffering from cold exposure because the plane plummeted and submerged into a local river. d. Call the nursing supervisor to activate the agency disaster plan. Autocratic * b. Which of the following would be the nurse's initial action? a. Which of the following instructions would the RN give to the NA? a. * d. Prominent U wave b. Laissez faire 19. A nurse attends an educational conference on leadership styles. b. Democratic d. Administer a Fleet enema.administered and that the client is still passing brown liquid stool. Call the laundry department and ask the department to send as many as warm blankets as possible to the emergency room. Shortened ST segment d. Widened T wave c.

21.0 mEq/L. Prologed PR interval . Prominent U wave b. Widened QRS complex d. Which ECG change would the nurse expect to note based on the magnesium level? a. Depressed ST segment * c. The nurse caring for a client with severe malnutrition reviews the laboratory results and notes a magnesium level of 1.

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