Foundations of Nursing Practice

Dynamic Learning Program v.2

1. A client has been instructed in crutchwalking techniques and has been fitted for crutches. Before the client begins ambulation, the nurse checks the fit of the crutches to ensure that there is a space between the axilla and the top crutch pad of
to 1 inch.

1 to 2 inches.
2 to 3 inches. 3 to 4 inches.

The answer is letter B. Providing a 1 - 2 inch space between the top of the crutch and the axilla will prevent undue pressure on the Brachial nerve which may lead to neuritis. Instruct the client that the proper use of crutches require the client to place the pressure on the palms of the hands, not the axilla

2. A nurse is assessing the learning readiness of a client newly diagnosed with diabetes mellitus. Which client behavior indicates to the nurse that the client is not ready to learn?
The client complains of fatigue whenever the nurse plans a teaching session. The client asks if the spouse can attend the teaching session. The client asks for written materials about diabetes mellitus before class.

The client asks appropriate questions about what will be taught.

The answer is letter A. Physical symptoms can interfere with an individuals ability to learn and also can indicate to the teacher that the learner lacks motivation to learn, if the symptoms repeatedly recur when teaching is initiated. Options 2, 3, and 4 identify active client participation in learning.

3. A nurse is providing information to a client scheduled for a lumbar puncture. Which information will the nurse provide to the client?
Food and fluids will be restricted until after the test. There is no need to maintain bed rest following the test. An informed consent form will be required. The test will probably take 2hours.

The answer is Letter C. Client preparation for a lumbar puncture includes obtaining an informed consent from the client. No dietary restrictions are required before the test. The client is told that the test will take 15 to 60 minutes. The nurse needs to inform the client about the need for bed rest following the test.

4. A clinic nurse notes that the physician has documented a suspected diagnosis of herpes zoster in the clients chart. The nurse would prepare the client for which diagnostic test that will confirm this diagnosis? Skin biopsy Woods light examination Culture of the lesion Patch test

The answer is Letter C - A viral culture of the lesion provides the definitive diagnosis A A biopsy identifies the tissue type. B In Woods Light examination, the skin is viewed under UV light to identify superficial infection of the skin. D A Patch test is a skin test that involves the administration of an allergen to the surface of the skin.

5. Which outcome would indicate successful treatment of diabetes insipidus?

Fluid intake of less than 2,500 ml in 24 hours Urine output of more than 200 ml/hour Blood pressure of 90/50 mm Hg Pulse rate of 126 beats/minute

Letter A A client with Diabetes Insipidus can excrete up to 8 liters of fluid Letter B - A urine output of 200 ml/hour indicates continuing polyuria. Letter C and D- Blood pressure at 90/50 mm Hg and a pulse rate of 126 beats/minute are signs of compensation for continued fluid deficit, suggesting that treatment hasn't been effective

6. Which of the following statements represents a major principle of chronic pain management?

A physiologic approach is most effective.

A psychological approach is most effective. A pharmacologic approach is most effective.

A multidisciplinary approach is most effective.

Letter D (Umbrella Option) - A multidisciplinary approach to pain relief is needed for greatest effectiveness. In addition to the client, the nurse, and the physician, others who may be needed on the team include a social worker, an occupational therapist, a dietitian, and a psychologist or a psychiatrist.

7. When performing a guaiac test on a patient's stool, the nurse is checking for the presence of which of the following?
White blood cells. Red blood cells. Ova and parasites.

Mucus.

The answer is Letter C. In Guaiac Testing or Occult Blood testing, the stool sample is visualized for the presence of red blood cells. The nurse should instruct the client to: 1) Avoid red meats 3 days before the procedure, 2) avoid or limit the intake of fiber, and 3) withhold the intake of Iron prior to the procedure.

8. A client who has a potassium level of 6 mEq/L should be treated with:

Kcl Infusion

Spironolactone (Aldactone)
fluid restriction. sodium polystyrene sulfonate (Kayexalate).

The Answer is Letter D. Kayexalate forces potassium to accumulate in the colon and be removed through the feces. Letter A and B are both incorrect since the client is already in a state of Hyperklaemia; both interventions would further increase Potassium

9. A nurse is studying nursing theorists and wants to find something to support the belief that caring, when providing care, includes a personal response on the part of the nurse. Which of the following theorists would support what this nurse is trying to find?
Jean Watson
Hildegard Peplau Florence Nightingale Virginia Henderson

Letter A. Human Caring Model Letter B. Interpersonal Model

Letter C. Environmental Theory

Letter D. 14 Basic Needs

10. In Martha Rogers' theory, which of the following describes the relationship of the parts of a living organism to the whole organism?
The sum of the parts is not related to the whole.

The sum of the parts is equal to the whole.

The whole is greater than the sum of the parts.

The sum of the parts is greater than the whole.

The answer is Letter C. in Martha Rogers Theory of Unitary Human being, the Whole of the person is more than the sum of all of its parts.

11. A client is admitted to the outpatient unit complaining of chest pain. The nurse assesses Erb's point. Erb's point is located in the:
left fifth interspace, midclavicular line. left second intercostal space. left third to fourth intercostal space.

right second intercostal space.

Erb's point is located in the left fifth intercostal space. The pulmonic area is the left second intercostal space. The aortic area is the right second intercostal space.

12. When performing an assessment on the client with emphysema, the nurse finds that the client has a barrel chest. The alteration in the client's chest is due to: Collapse of distal alveoli Hyperinflation of the lungs Long-term chronic hypoxia

Use of accessory muscles

The Answer is Letter B. Clients with emphysema develop a barrel chest due to to trapping of air in the lungs, causing them to hyperinflate. Answers C and D are common in those with emphysema but not cause the chest to become barrel shaped. Answer A does not occur in emphysema.

13. While inspecting the client's chest, the nurse notes that the chest wall contracts on inspiration and bulges on expiration. From this assessment, she suspects
hemothorax. flail chest. pneumothorax.

tension pneumothorax.

The Answer is Letter B. Flail chest occurs when two or more adjacent ribs are fractured at two or more sites, resulting in a freefloating segment. A tension pneumothorax causes a mediastinal shift and tracheal deviation toward the unaffected side.

14. What is the most appropriate nursing diagnosis for the client with acute pancreatitis?
Deficient fluid volume

Excess fluid volume

Decreased cardiac output Ineffective gastrointestinal tissue perfusion

The Answer is Letter A. Clients with acute pancreatitis commonly experience deficient fluid volume, which can lead to hypovolemic shock. The volume deficit may be caused by vomiting, hemorrhage (in hemorrhagic pancreatitis), and plasma leaking into the peritoneal cavity.

15. To prevent external rotation of the client's hips while he is lying on his back, it would be best for the nurse to place:
Firm pillows under the length of his legs. Sandbags alongside his legs from knees to ankles. Trochanter rolls alongside his legs from ilium to midthigh.

A footboard that supports his feet in the normal anatomic position.

The Answer is Letter C. Trochanter rolls placed alongside the client's legs from the ilium to midthigh are recommended to prevent external rotation of the hips. A: Pillows can be used only as a temporary measure because they cannot hold the legs and hips in proper alignment over a prolonged period. B: Placing sandbags from the knees to the ankle will not effectively support the hips in proper alignment. D: A footboard does not help to keep the legs and hips in proper alignment.