Fundamentals pre-assessment quiz with Correct Questions and Answers.A nurse is caring for a client with a stage 2 pressure ulcer. Define the characteristics of the ulcer. Answer - Partial-thickness skin loss involving the epidermis and the dermis.The ulcer is visible and superficial and may appear as an abrasion, blister, or shallow crater. Edema persists, and the ulcer may become infected, possibly with pain and scant drainage.A nurse is caring for a client receiving chemotherapy that is experiencing neutropenia.Which of the following should the nurse include in this client's education? Answer - Avoid crowded events Clients with neutropenia do not have enough circulating neutrophils to fight off infections. This client should avoid crowds to prevent exposure to colds/viruses.A nurse is caring for a client who is admitted for observation and has full range of motion. Which is the best manner to encourage this client to void? Answer - client bathroom The goal is to encourage clients to maintain independence and privacy if the client has full function and is able to safely complete ADLs.A client with hearing loss has been fitted for a hearing aid. Which of the following teaching points are important for the nurse to discuss with the client? Answer - Use a mild soap and water to clean the ear mold.A nurse is caring for an older adult client with delirium. Which intervention will most effectively reduce the client's risk for falls? Answer - hourly rounding by the nurse In the health care environment, hourly rounding by nurses significantly reduces the occurrence of client falls, as well as reducing call light usage and increasing client satisfaction.A nurse is providing teaching about the Mediterranean diet to a client who has a new diagnosis of hypertension. Which of the following statements by the client indicates a need for further teaching? Answer - "I will limit my intake of red meat to twice weekly" 1 / 2
This statement by the client indicates a need for further teaching. Following the Mediterranean diet, red meat should be limited to two times monthly.A nurse is admitting a client who has tuberculosis and a productive cough. Which of the following types of isolation precautions should the nurse initiate for the client? Answer - Airborne The nurse should initiate airborne precautions when a client has an infection that spreads through small droplets that remain airborne for longer periods, such as tuberculosis and measles. The client requires a negative-pressure airflow room, and staff should wear an N95 respirator when in contact with the client.A nurse is assessing a client who has Parkinson's disease. Which of the following manifestations should the nurse expect? Answer - Bradykinesia The nurse should expect to find bradykinesia or difficulty moving in a client who has Parkinson's disease A nurse is caring for a client with celiac disease. Which foods should be removed from the meal tray? Answer - tortillas A nurse is caring for a client with a closed head injury. When pressure is applied to the client's nail beds, the client's eyes open and adduction of the arms with flexion of the elbows and wrists is noted. The client also moans with stimulation. What is the client's Glasgow Coma Score? Answer - 7 The GCS is calculated by using appropriate stimuli (a painful stimulus may be necessary such as pressure to the nail beds) and then assessing the client's response in three areas.Eye opening (E)- the best eye response, with responses ranging from 4 to 1 4= Eye opening occurs spontaneously 3= Eye opening occurs secondary to voice 2= Eye opening occurs secondary to pain 1= Eye opening does not occur Verbal (V)- The best verbal response, with responses ranging from 5 to 1 5= Conversation is coherent and oriented 4= Conversation is incoherent and disoriented 3= Words are spoken, but inappropriately 2= Sounds are made, but no words 1= Vocalization does not occur Motor (M)- The best motor response, with responses ranging from 6 to 1
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