Fundamental Skills Questions

Chapter 13

Fundamental Skills Questions

1. The nurse develops a plan of care for a newly hospitalized client who reports difficulty sleeping. The nurse plans to implement which best intervention?

1. Offer the client a sleeping pill at night.

2. Provide the client with a snack at bedtime.

3. Ask the client what the client does to prepare for sleep.

4. Leave the television on in the client’s room at a very low volume.

Level of Cognitive Ability:

Client Needs:

Physiological Integrity

Integrated Process:

Nursing Process/Assessment/Data Collection

Content Area:

Fundamental Skills

ANSWER: 3

Rationale:

The best intervention is to ask the client what the client does to prepare for sleep. The nurse needs to assess habits that are beneficial to the client compared with those that disturb sleep. Options 1, 2, and 4 provide interventions without assessing what measures would be helpful to the client.

Test-Taking Strategy:

Note the strategic word best, and use the steps of the nursing process. The only option that addresses assessment/data collection is option 3. Review: care of the client experiencing difficulty sleeping.

Tip for the Beginning Nursing Student:

You will learn about sleep patterns and measures to promote sleep in your fundamentals of nursing course. An important point to remember is that you always want to determine what measures the client takes at home to sleep and incorporate these measures in the plan of care during hospitalization.

References

Christensen, Kockrow: Foundations (2011), pp. 410, 413-414; Potter et al (2013), pp. 949-950.

2. The nurse notes documentation in a client’s medical record that the client is experiencing anuria. Based on this notation, what determination should the nurse make?

1. The client is unable to produce urine.

2. The client has a diminished capacity to form urine.

3. The client has difficulty having a bowel movement.

4. The client has episodes of alternating constipation and diarrhea.

Level of Cognitive Ability:

Client Needs:

Physiological Integrity

Integrated Process:

Nursing Process/Assessment/Data Collection

Content Area:

Fundamental Skills

ANSWER: 1

Rationale:

Anuria is the term used to describe an inability to produce urine. Oliguria is a diminished capacity to form urine and is most likely the result of a decrease in renal perfusion. Options 3 and 4 do not relate to urinary tract dysfunction.

Test-Taking Strategy:

Focus on the subject, the definition of anuria. Use medical terminology skills to answer the question. Recalling that the prefix an– refers to absence and the suffix –uria refers to urine will direct you to the correct option. Review: the definition of anuria.

Tip for the Beginning Nursing Student:

You will learn about the terminology used to describe conditions related to the renal system in your fundamentals of nursing course and your medical-surgical nursing course when you study renal disorders. It is important to remember that the client should maintain a urinary output of at least 30 mL/hour and the nurse should monitor for this occurrence. A decline in urine output could indicate kidney dysfunction or failure, hypovolemia, or an obstruction in the renal system. This occurrence needs to be reported.

References

deWit, Kumagai (2013), p. 789; Ignatavicius, Workman (2013), p. 1474.

3. The nurse is caring for a client who has a fever and is diaphoretic. The nurse monitors the client’s intake and output and expects which finding?

1. The client’s urine is diluted.

2. The client’s output is decreased.

3. The client’s urine production is increased.

4. The majority of the client’s fluid is excreted through the skin.

Level of Cognitive Ability:

Client Needs:

Physiological Integrity

Integrated Process:

Nursing Process/Assessment/Data Collection

Content Area:

Fundamental Skills

ANSWER: 2

Rationale:

Febrile conditions affect urine production. The client who is diaphoretic loses fluids through insensible water loss, which decreases urine production. However, the increased body temperature associated with fever increases accumulation of body wastes. Although urine volume may be reduced, it is highly concentrated. Some fluid (not the majority) will be lost through the skin. Options 1, 3, and 4 are incorrect.

Test-Taking Strategy:

Focus on the subject, care of the client experiencing a fever and diaphoresis. This will direct you to the correct option because this client will also be losing some (not the majority) fluid through the skin. Review: conditions that affect fluid balance.

Tip for the Beginning Nursing Student:

You will learn about fluid balance and monitoring intake and output in your fundamentals of nursing course. An important point to remember is that fluid can be lost through the skin, the lungs during breathing, the kidneys, and the gastrointestinal tract. Normally most fluid is lost through the kidneys, but if the client has a fever and is diaphoretic (sweating), more than the normal amount is lost through the skin and less than the normal amount is lost through the kidneys.

References

Ignatavicius, Workman (2013), pp. 176-177; Linton (2012), pp. 202-203.

4. The nurse provides instructions to a female client regarding the procedure for collecting a midstream urine sample. The nurse should tell the client to perform which action?

1. Douche before collecting the specimen.

2. Cleanse the perineum from front to back.

3. Collect the urine in the cup as soon as the urine flow begins.

4. Collect the specimen before bedtime, and bring it to the laboratory the next morning.

Level of Cognitive Ability:

Client Needs:

Safe and Effective Care Environment

Integrated Process:

Teaching and Learning

Content Area:

Fundamental Skills

ANSWER: 2

Rationale:

As part of correct procedure, the client should cleanse the perineum from front to back with the antiseptic swabs that are packaged with the specimen kit. The client should begin the flow of urine, collecting the sample after starting the flow of urine. The specimen should be sent to the laboratory as soon as possible and not allowed to stand. Improper specimen handling can yield inaccurate test results. It is not normal procedure to douche before collecting the specimen.

Test-Taking Strategy:

Focus on the subject, urine collection for laboratory analysis. Noting the name of the type of sample—midstream—will assist in eliminating option 3. Recalling that the specimen should be sent or brought to the laboratory immediately after collection will assist in eliminating option 4. From the remaining options, use basic principles related to hygiene and infection control to assist in directing you to the correct option. Review: the procedure for collecting a midstream urine sample.

Tip for the Beginning Nursing Student:

You will learn about basic hygiene principles, asepsis, and collecting urine specimens in your fundamentals of nursing course. An important client teaching point to remember is that the female client is taught to always wipe or cleanse the perineum from front to back to prevent the spread of microorganisms from the rectal area to the labial area, which could result in a urinary tract infection. Additionally, the male client is instructed to cleanse the penis with the towelettes, cleansing from the meatus outward, and retracting foreskin if present.

References

Christensen, Kockrow: Foundations (2011), pp. 495-496; Ignatavicius, Workman (2013), p. 1479.

5. The nurse provides dietary instructions to a client diagnosed with iron deficiency anemia. The nurse should tell the client to increase the intake of which food item?

4. Kidney beans

Level of Cognitive Ability:

Client Needs:

Physiological Integrity

Integrated Process:

Teaching and Learning

Content Area:

Fundamental Skills

ANSWER: 4

Rationale:

The client with iron deficiency anemia should increase intake of foods that are naturally high in iron, including kidney beans, soybeans, chickpeas, lima beans, cooked Swiss chard, red meat, liver and other organ meats, blackstrap molasses, lentils, egg yolk, spinach, kale, turnip tops, beet greens, carrots, raisins, and apricots. The food items in options 1, 2, and 3 are not high in iron.

Test-Taking Strategy:

Focus on the subject, a food high in iron. Eliminate options 1 and 2 first because they are comparable or alike and are fruit items. From the remaining options, recall either that beans are high in iron or that egg yolk (not egg white) is high in iron. This will direct you to the correct option. Review: food items high in iron.

Tip for the Beginning Nursing Student:

Iron deficiency anemia is a condition in which the client lacks sufficient red blood cells. One cause is an insufficient intake of dietary iron. You will learn about anemia in your fundamentals of nursing course and in your medical-surgical nursing course when you study hematological disorders. You will also learn about the foods high in iron when you study nutrition. These food items are important to know because you will be teaching your client about a high-iron diet.

References

deWit, Kumagai (2013), pp. 347-348; Ignatavicius, Workman (2013), pp. 876-870; Schlenker, Roth (2011), p. 153.

6. A client asks the nurse about the use of a complementary or alternative measure that will assist in promoting sleep. The nurse should make which suggestion?

1. Herbal therapy

2. Acupuncture sessions

3. Muscle relaxation techniques

4. Traditional Chinese medicine sessions

Level of Cognitive Ability:

Client Needs:

Physiological Integrity

Integrated Process:

Nursing Process/Implementation

Content Area:

Fundamental Skills

ANSWER: 3

Rationale:

A simple relaxation technique, such as muscle relaxation, can help reduce any existing anxiety and promote sleep. Herbal therapy involves the use of herbs (plant or a plant part). Some herbs have been determined to be safe, but other herbs, even in small amounts, can be toxic and the nurse would not recommend their use to a client. The client who is taking prescription medications should consult the health care provider regarding the use of herbs because serious herb-medication interactions can occur. Acupuncture is an invasive procedure that stimulates certain points on the body by the insertion of special needles to modify the perception of pain, normalize physiological functions, or treat or prevent disease. Traditional Chinese medicine focuses on restoring and maintaining a balanced flow of vital energy; interventions include acupressure, acupuncture, herbal therapies, diet, meditation, and tai chi and qi gong (exercise that focuses on breathing, visualization, and movement). Any invasive therapy requires a prescription from the health care provider.

Test-Taking Strategy:

Note the relationship between the words promoting sleep and option 3. Also note that options 1, 2, and 4 are comparable or alike in that they include invasive measures. Review: complementary and alternative therapies.

Tip for the Beginning Nursing Student:

Complementary and alternative therapies include nontraditional and non-Western medical forms of treatment and may be prescribed to supplement existing medical therapies. They must be prescribed by the health care provider. You will learn about complementary and alternative therapies in your fundamentals of nursing course and your pharmacology course. An important point to remember is that the nurse would not recommend the use of these treatments, especially invasive ones, without first consulting the health care provider. Some of these therapies can harm the client.

References

Christensen, Kockrow: Foundations (2011), p. 399; Potter et al (2013), pp. 644, 647-648.

7. The nurse instructs a client taking a potassium-retaining diuretic about foods high in potassium that need to be avoided. The nurse determines that the client needs further instruction if the client states that which food is high in potassium?

Level of Cognitive Ability:

Client Needs:

Physiological Integrity

Integrated Process:

Teaching and Learning

Content Area:

Fundamental Skills

ANSWER: 2

Rationale:

Meats, some dairy products, dried fruits, bananas, cantaloupe, kiwi, and oranges are high in potassium. Vegetables that are high in potassium include avocados, broccoli, dried beans or peas, lima beans, mushrooms, potatoes, seaweed, soybeans, and spinach. Celery is a vegetable that is low in potassium.

Test-Taking Strategy:

Note the strategic words needs further instruction. These words indicate a negative event query and indicate that you need to select the option that is an incorrect client response. Eliminate options 1, 3, and 4 because they are comparable or alike and are fruit items. Review: food items high and low in potassium.

Tip for the Beginning Nursing Student:

A diuretic is a medication that promotes the formation and excretion of urine and leads to an increase in urine output. These medications are used for clients with excess body fluid, such as those with hypertension or heart failure. Many diuretics cause the loss of potassium in the urine. A potassium-retaining diuretic does not, and the client tends to retain potassium rather than lose it. The client is taught about diet and the foods that are high and low in potassium. Both a low potassium level and a high potassium level can cause serious problems for the client; therefore, potassium imbalances are important to learn. You will learn about potassium imbalances and nutrition in your fundamentals of nursing course, and you will learn about diuretics in your pharmacology course.

References

deWit, Kumagai (2013), p. 44; Ignatavicius, Workman (2013), pp. 186-187; Schlenker, Roth (2011), pp. 145-146.

8. A clear liquid diet has been prescribed for a client. The nurse should offer which item to the client?

2. Orange juice

3. Tomato juice

4. Ice cream without nuts

Level of Cognitive Ability:

Client Needs:

Physiological Integrity

Integrated Process:

Nursing Process/Implementation

Content Area:

Fundamental Skills

ANSWER: 1

Rationale:

A clear liquid diet consists of foods that are relatively transparent. The food items in options 2, 3, and 4 would be included in a full liquid diet.

Test-Taking Strategy:

Eliminate options 2, 3, and 4 because they are comparable or alike and are items allowed on a full liquid diet. Remember that a clear liquid diet consists of foods that are relatively transparent. Option 1 is the only food item that is transparent. Review: food items allowed on a clear liquid diet and full liquid diet.

Tip for the Beginning Nursing Student:

A clear liquid diet may be prescribed to provide fluids to treat or prevent dehydration, to provide complete bowel rest, to feed a malnourished person or a person who has not had any oral intake for some time, in preparation for surgery or tests, or as a postsurgical diet. A clear liquid diet consists of foods that are relatively transparent. You will learn about this type of diet and other diets in your fundamentals of nursing course.

References

Christensen, Kockrow: Foundations (2011), p. 630; Potter et al (2013), p. 1017.

9. Oxygen by nasal cannula at 4 L/minute is prescribed for a hospitalized client. The nurse should perform which action(s) in the care of the client? Select all that apply.

1 Humidify the oxygen.

2 Apply water-soluble lubricant to the nares.

3 Instruct the client to breathe through the nose only.

4 Instruct the client and family about the purpose of the oxygen.

5 Increase the oxygen flow if the client complains of dryness in the nares.

Level of Cognitive Ability:

Client Needs:

Physiological Integrity

Integrated Process:

Nursing Process/Implementation

Content Area:

Fundamental Skills

ANSWER: 1, 2, 4

Rationale:

The nasal cannula provides for lower concentrations of oxygen and can even be used with mouth breathers because movement of air through the oropharynx pulls oxygen from the nasopharynx. The nurse should humidify the oxygen and apply water soluble lubricant to the nares to prevent and treat dryness. The nurse should also instruct the client and family regarding the purpose of the oxygen. It is not necessary to instruct a client to breathe only through the nose. It is unnecessary and potentially harmful to increase the oxygen flow; this action requires a health care provider’s prescription. Additionally, increasing the flow of oxygen will contribute further to dryness of the nares.

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Tags: Saunders 2014-2015 Strategies for Test Success Passing Nursing S

Jul 24, 2016 | Posted by admin in NURSING | Comments Off

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