Fundamentals Of Nursing

Front 1

What is a licensed nurse responsible for when delegating a task?

Back 1

Providing clear instructions, evaluating, and reassessing.

Front 2

What can RN not delegate to an LPN?

Back 2

Are not delegate nursing process, client education, or tasks that require nursing judgement to LPN.

Front 3

What are the 5 rights of delegation?

Back 3

Right task
Right circumstance
Right person
Right communication
Right supervision

Front 4

What are the three tasks that are appropriate to delegate for each specific client?

Back 4

A task that is repetitive, requires little supervision, and is relatively noninvasive.

Front 5

A nurse has received change of shift report and will care for four clients. Which of the following client's needs may the nurse assign to an assistive personnel (AP)?
1. Feeding a client who was admitted 24 hours ago with aspiration pneumonia.
2. Reinforcing teaching with a client who is learning to walk using a quad cane.
3. Reapplying a condom catheter for a client who has urinary incontinence.
4. Applying a sterile dressing to a pressure ulcer.

Back 5

3. This is a noninvasive, routine procedure that the nurse may delegate.

Front 6

A nurse is delegating the ambulation of a client who had knee arthroplasty 5 days ago to an AP. WHich of the following information should the nurse share with the AP? (Select all that apply)
1. The roommate is up independently
2. The client ambulates with his slippers on over his anti embolic stock ins
3. The client uses a front-wheeled walker when ambulating
4. The client had pain meds 30 min ago
5. The client is allergic to codeine.
6. The client ate 50% of his breakfast.

Back 6

2.
3.
4.

Front 7

An RN is making assignments for client care to an LPN at the beginning of the shift. Which of the following assignments should the LPN question?
1. Assisting a client who is 24 hour postoperative to use an incentive spirometer
2. Collecting a clean-catch urine specimen from a client who was admitted on the previous shift.
3. Providing nasopharyngeal suctioning for a client who has pneumonia.
4. Replacing the cartridge and tubing on a patient-controlled analgesia (PCA) pump.

Back 7

4. The RN is responsible for this.

Front 8

A nurse is preparing an in-service program about delegation. Which of the following elements should she identify when presenting the five rights of delegation? (Select all that apply)
1. Right client
2. Right supervision/evaluation
3. Right direction/communication
4. Right time
5. Right circumstances

Back 8

2.
3.
5.

Front 9

A nurse manager is assigning care responsibilities for the oncoming shift. A client is awaiting transfer back to the unit from the PACU following thoracic surgery. To which staff member should the nurse assign to this client?
1. Charge nurse
2. RN
3. LPN
4. AP

Back 9

2. RN. Client needs assessment and establishment of a plan of care. RN's are responsible for this.

Front 10

When does discharge planning occur?

Back 10

At admissions

Front 11

During the admission process, provide information about _____ _________.

Back 11

Advanced directives

Front 12

What should you do with personal items?

Back 12

Document leaving items at bedside but first discourage keeping the valuables there.

Front 13

A nurse is performing an admission assessment for an older adult client. After gathering the assessment data and performing the review of systems, which of the following actions is a priority for the nurse?
1. Orient the client to his room.
2. Conduct a client care conference.
3. Review the client's medical orders
4. Develop a plan of care.

Back 13

1. The greatest risk to this client is injury from unfamiliar surroundings.The client must know where the call light is and other equipment before RN leaves room.

Front 14

A nurse is admitting a client who has acute cholecystitis to a medical-surgical unit. Which of the following actions are essential steps of the admission procedure. (Select all that apply)
1. Explain the roles of other care delivery staff.
2. Begin discharge planning
3. Provide information about advance directives
4. Document the clients wishes about organ donation.
5. Introduce the client to his roommate.

Back 14

1.
2.
3.
5.

Front 15

Which of the following information should the nurse include about a client in a transfer report? (Select all that apply)
1. Alert and oriented
2. Refuses to eat spinach
3. Has a shellfish allergy
4. Requests morphine every 4 hours
5. Misses the two cats he has at home

Back 15

1.
3.
4.

Front 16

Which of the following information should a nurse include in discharge summary?
1. Advance directives status
2. Where to go for follow-up care
3. Instructions for diet and medications
4. Most recent vital sign data
5. Contact information for the home health care agency

Back 16

2.
3.
5.

Front 17

As part of the admission process, a nurse at a long-term care facility is gathering a nutrition history for a client who has dementia. Which of the following components of the nutrition evaluation is the priority for a nurse to determine from the clients family?
1. Body mass index
2. Usual times for meals and snacks
3. Favorite foods
4. Any difficulty swallowing

Back 17

4.

Front 18

When is the most optimal time to do a self breast exam?

Back 18

2 or 3 days after menstruation ends

Front 19

What are the four positions to conduct a breast exam?

Back 19

Female:
Arms at side
Arms above head
Hands on hips pressing firmly
Leaning forward (arms out in front or on hips

Front 20

What are three expected sounds during auscultation of the lungs? What do they sound like?

Back 20

Bronchial: loud, high pitched expiration longer than inspiration over trachea
Bronchovesicular: medium pitch and intensity with equal inspiration and expiration times over the larger airways
Vesicular: soft, low pitched, inspiration three times longer than expiration over most areas of the lungs.

Front 21

Define crackles, wheezes, rhonchi, and pleural friction rub.

Back 21

Crackles: fine to coarse popping (not cleared with coughing)
Wheezes: high pitched whistling, musical sounds as air passes through narrowed or obstructed airways
Rhonchi: coarse sounds during either inspiration or expiration resulting from fluid or mucus
Pleural friction rub: grating sound as the inflamed visceral and parietal pleura rub against each other

Front 22

What does the closing of the mitral and tricuspid valves signal?

Back 22

Beginning of ventricular systole (contraction) and it produces the S1 sounds

Front 23

What does the closuree of the aortic and pulmonic valves signal?

Back 23

Beginning of the ventricular diastole (relaxation) and produces the S2 sound

Front 24

What does an S3 reflect?

Back 24

Indicates rapid ventricular filling and can be an expected finding in children and young adults. Produces a ventricular gallop that can be heard with the bell of the stethoscope

Front 25

What does an S4 reflect?

Back 25

Strong atrial contraction and can be an expected finding in older and athletic adults and children. Use bell.

Front 26

What is a bruit?

Back 26

Blowing or swishing sound that indicates obstructed peripheral blood flow. Use bell.

Front 27

What angle of the bed should the patient be to inspect jugular veins? What does this inspection assess for?

Back 27

30' to 45' angle. Inspects for right-sided heart failure.

Front 28

What is a convex shape in relationship to the abdomen?

Back 28

Rounded shape

Front 29

What is a flatus shape to an abdomen?

Back 29

Protrusion is mainly midline and there is no change in the flanks

Front 30

What is an expected finding for a normal liver span?

Back 30

2.4-4.7 inches

Front 31

Which of the followings is a normal finding in a breast examination in an older adult? (select all that apply)
1. Smaller nipples
2. Less adipose tissue
3. Nipple discharge
4. More pendulous
5. Nipple inversion

Back 31

1.
4.
5.

Front 32

Which of the followings is a normal finding when auscultating and percussing a clients thorax?
1. Rhonchi
2. Crackles
3. Resonance
4. Tactile fremitus
5. Bronchovesicular sounds

Back 32

3.
4.
5.

Front 33

During an abdominal examination, nurse observes that client has distention. The protrusion is at midline, the skin over the area is taut, and the nurse notes no involvement of the flanks. Which of the followings causes is correct?
1. Fat
2. Fluid
3. Flatus
4. Hernias

Back 33

3. Flatus

Front 34

Nurse places stethoscope on the left midclavicular line at the 5th intercostal space. Which of the following heart sounds is the nurse attempting to auscultate? (Select all that apply).
1. Ventricular gallop
2. Closure of the mitral valve
3. Closure of the pulmonic valve
4. Closure of the tricuspid valve
5. Murmur

Back 34

2.
4.

Front 35

A nurse is preparing to auscultate and percuss a clients abdomen. Which of the following findings should the nurse expect? (Select all that apply).
1. Tympany
2. High pitched clicks
3. Borborygmi
4. Friction rubs
5. Bruits

Back 35

1.
2.

Front 36

What is intrapersonal communication?

Back 36

Internal discussion that takes place when an individual is thinking but not outwardly talking.

Front 37

What is transpersonal communication?

Back 37

Communication that addresses spiritual needs and provides interventions to meet the needs.

Front 38

What is a referent component in basic communication?

Back 38

Incentive or motivation for communication to occur between one person and another

Front 39

What is donotative/connotative meaning?

Back 39

When communicating, participants must share meanings. Words that have multiple meanings may cause miscommunication.

Front 40

A nurse is caring for a client who states, "I have to check with my wife and see if she thinks I am ready to be discharged." The nurse replies, "How do you feel about going home?" Which clarifying technique is this?
1. Pacing
2. Reflecting
3. Paraphrasing
4. Restating

Back 40

2. Reflecting

Front 41

Client is concerned about a new colostomy because he is an avid swimmer. Which of the following statements is correct from the nurse? (select all that apply).
1. "You will do great! You just have to get used to it!"
2. "Why are you worried about going home?"
3. "Your daily routines will be different when you get home?"
4. "Tell me about your support system"
5. "Let me tell you about a friend of mine who has a colostomy bag and also enjoys swimming!"

Back 41

3.
4.
5.

Front 42

A nurse recoggnizes that a helping relationship is established with a client if the communication
1. is equally reciprocal between the nurse and the client
2. encourages the client to express his thoughts and feelings
3. has no time limits
4. occurs spontaneously throughout the nurse-client relationship

Back 42

2.

Front 43

Which of the following are behaviors of active listening? (select all that apply).
1. Maintaining an open posture
2. Writing down what the client says so that details are not lost
3. Establishing and maintaining eye contact
4. Nodding in agreement with the client throughout the conversation
5. Responding positively when giving feedback.

Back 43

1.
3.
5.