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Fundamentals Exam

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 Rationale: Morphine can cause respiratory depression if given too much. Also you

should ALWAYS ASSESS the patient first when a med error is performed to make

sure med error doesn‟t put the client‟s health in risk.

4. A nurse is preparing to administer diphenhydramine 20 mg orally to a 6-year-old child who

has difficulty swallowing pills. Available is diphenhydramine 12.5 mg/5 mL oral syrup.

Which of the following images shows the correct # of mL the nurse should administer?

(Round the answer to the nearest whole number.)

Click on the syringe that has 8 mL of med.

20 mg x (5mL/12.5mg) = 8 mL

5. A nurse is caring for a 6-year-old child who has a new prescription for cefoxitin 80

mg/kg/day administered intravenously every 6 hour. The child weighs 20 kg. How much

cefoxitin should the nurse administer with each dose? (Round the answer to the nearest whole

number. Use a leading zero if it applies. Do not use a trailing zero.)

 So it says each dose for the final answer, but we are given 80 mg/kg/day.

 80 x 20 = 1600 / 4 (dose is given every 6 hours a day) =400 mg

Rationale: 80 mg x 20 kg = 1,600  1,600/4 x day (q6h) = 400 mg

6. A nurse is preparing to administer IV fluids to a client. The nurse notes sparks when plugging

in the IV pump. Which of the following actions should the nurse take first?

a. Label the pump with a defective equipment sticker.

b. Unplug the pump.

c. Obtain a replacement pump.

d. Notified the biomedical department to fix the pump.

 Rationale: Prioritization question. YOU WILL FIRST UNPLUG the IV pump to avoid

causing a fire.

7. A nurse is caring for a client who has a surgical wound. Which of the following laboratory

values places the client at risk for poor wound healing?

a. Serum albumin 3 g/dL

b. Total lymphocyte count 2400 mm3

c. HCT 42%

d. HGB 16g/dL

 Rationale: Albumin in low. Normal range is 3.5 to 5.5 g/dL. Low albumin places the

client at risk forpoor wound healing. The other lab values are within normal limits.

8. A nurse is preparing to check a client's blood pressure. Which of the following actions should

the nurse take? Chapter 27 Vitals signs page 244

a. Apply the cuff above the client‟s antecubital fossa.

b. Use a cuff with a width that is about 60% of the client's arm circumference. - width of the

cuff should be 40 % of arm circumference

c. How the clients sit with his arm resting above the level of his heart. - MUST BE AT

HEART LEVEL

d. Release the pressure on the client's arm 5 to 6 mm per second. - pressure release should

not be more than 2 to 3 mm hg per second

 Rationale: ATI FUNDA says 40% of the arm circumference pg. 139. Release the

pressure no faster than 2 to 3 mm Hg per second. Apply the BP cuff 2.5 cm (1 in) above

the antecubital space with the brachial artery in line with the marking on the cuff.Apply

the BP cuff 2.5 cm (1 in) above the antecubital space with the brachial artery in line with

the marking on the cuff.

9. A nurse is preparing to perform nasal tracheal suctioning for a client. Which of the following

is an appropriate action for the nurse to take? Chapter 53 Airway management page 563

a. Hold the suction catheter with the clean non-dominant hand.

b. Apply suctioning for 20 to 30 seconds.- 10 -15 seconds is the maximum.

c. Place the catheter in a location that is clean and dry for later use new line.- NEVER

EVER REUSE THE SUCTION CATHETER . you throw it away after being used.

d. Use surgical asepsis when performing the procedure.- book say medical asepsis

which is maybe the same thing .

 Rationale: sterile technique for trachea

 Rationale: ATI FUNDA. PG. 316 Use surgical asepsis for all types of suctioning. No

longer than 10-15 seconds to avoid hypoxemia

10. A nurse is documenting client care. Which of the following abbreviations should the nurse

use?ati book was not thorough so i had to go on different sites for charts - not confident with this,

please double check.

a. “SS” for sliding scale

b. “BRP” for bathroom privileges

c. “OJ” for orange juice- do not

d. “SQ” for subcutaneous- do not

11. MISSING

12. A nurse is collecting A blood pressure reading from a client who is sitting in a chair period

the nurse determines that the clients BP is 158/96 mmhg. which of the following actions should

the nurse take?

a. Ensure that the width of the BP cuff is 50% of the client‟s upper arm circumference. It

says 40%

b. Reposition the client Supine and recheck her BP. BP. → ORTHOSTATIC

HYPOTENSION

c. Recheck the clients BP and her other arm for comparison.

d. Request that another nurse check the the clients BP in 30 minutes. → 15 minutes

13. A nurse is caring for a client who has left lower atelectasis. in which of the following

positions should the nurse place the client for postural drainage? Chapter 53 Airway

Management page 562

e. Supine and low-Fowler's position

f. Right lateral in Trendelenburg position

g. Side lying with the right side of the chest elevated

h. Prone with pillows under the extremities