RN Fundamentals online practice 2016 A Study online at quizlet.

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1. A
nurse in a clinic is caring for a middle adult client who states, "The doctor says that, since I am at an average risk for
colon cancer, I should have a routine screening. What does that involve?" Which of the following responses should the
nurse make?

A. "I'll get a blood sample from you and send it for a screening test."

B. "Beginning at age 60, you should have a colonoscopy."

C. "You should have a fecal occult blood test every year."

D. "The recommendation is to have a sigmoidoscopy every 10 years.": C. "You should have a fecal occult blood test every
year."

Colorectal cancer screening for clients at average risk begins at age 50. One option for screening is a fecal occult blood test
annually.

2. A
nurse is caring for a client who is having difficulty breathing. The client is lying in bed with a nasal cannula delivering
oxygen. Which of the following interventions should the nurse take first?

A. Suction the client's airway

B. Administer a bronchodilator
C.Increase the humidity in the client's room
D. Assist the client to an upright position: D. Assist the client to an upright position

When providing client care, the nurse should first use the least invasive intervention. Therefore, the nurse should elevate
the head of the client's bed to the semi-Fowler's or high Fowler's position to facilitate maximal chest expansion. Sitting
upright improves gas exchange and prevents pressure on the diaphragm from abdominal organs.

3. A
nurse is preparing to administer 0.5 mL of oral single-dose liquid medication to a client. Which of the following actions
should the nurse take?

A. Gently shake the container of medication prior to administration

B. Transfer the medication to a medicine cup
C. Place the client in a semi-Fowler's position prior to medication administration
D. Verify the dosage by measuring the liquid before administration: A. Gently shake the container of medication prior to
administration

The nurse should gently shake the liquid medication to ensure the medication is mixed.

4. A
nurse is planning care to improve self-feeding for a client who has vision loss. Which of the following interventions
should the nurse include in the plan of care?

A. Tell the client which food should should eat first.

B. Provide small-handle utensils for the client.
C. Thicken liquids on the client's tray
D. Use a clock pattern to describe food on the client's plate: D. Use a clock pattern to describe food on the client's plate

Describing the location of the food on the plate by using a clock pattern allows the client to have greater independence
during meals.

5. Anurse is teaching an older adult client who is at risk for osteoporosis about beginning a program of regular physical
activity. Which of the following types of activity should the nurse recommend?
A. Walking briskly
B. Riding a bicycle
C. Performing isometric exercises
D. Engaging in high-impact aerobics: A. Walking briskly

Weight-bearing exercises are essential for maintaining bone mass, which helps to prevent osteoporosis. Walking engages
older adult clients in this preventive and therapeutic strategy.

6. Anurse is assessing a client's readiness to learn about insulin administration. Which of the following statements should
the nurse identify as an indication that the client is ready to learn?

A. "I can concentrate best in the morning."

B. "It is difficult to read the instructions because my glasses are at home."
C. "I'm wondering why I need to learn this."
D. "You will have to talk to my wife about this.": A. "I can concentrate best in the morning."

The client's statement indicates a readiness to learn because he is verbalizing the best time for him to learn.

7. Anurse is giving discharge instructions to a client who will require oxygen therapy at home. Which of the following
statements should the nurse identify as an indication that the client understands how to manage this therapy at home?

A. "I'll make sure that, when my friend comes by, she smokes at least 6 feet away from my oxygen.
B. "I'll use a woolen blanket if I get chilly while I'm using my oxygen.
C. "I'll check the wires and cables on my TV to make sure they are in good working order.
D. "I'll lay my oxygen tank down on the floor when the grandchildren visit so they don't knock it over.: C. "I'll check the
wires and cables on my TV to make sure they are in good working order.

Oxygen is a highly flammable gas. The client should make sure any electrical equipment in the room where she is using
supplemental oxygen is functioning properly so it does not create any electrical sparks.

The visitors should smoke outside the house.

Woolen and synthetic materials can create sparks, so the client should use a cotton blanket during O2 therapy.

8. A
nurse is caring for a client who is reporting difficulty falling asleep. Which of the following measures should the nurse
recommend?

A. Drink a cup of hot cocoa before bedtime

B. Exercise 1 hr before going to bed
C. Use progressive relaxation techniques at bedtime
D. Reflect on the day's activities before going to bed: C. Use progressive relaxation techniques at bedtime

Progressive relaxation promotes sleep by decreasing stress and reducing muscle tension. Cocoa contains caffeine, a
stimulant, and can interfere with sleep.
Exercising within 2 hr of bedtime can interfere with sleep.
Reflecting can cause stress and worry, which can interfere with sleep.

9. A
nurse is assisting a client who is postoperative with the use of an incentive spirometer. Into which of the following
positions should the nurse place the client?

A. Side-lying
B. Supine
C. Semi-Fowler's
D. Trendelenburg: C. Semi-Fowler's

Positioning the client in semi-Fowler's or high-Fowler's position allows for maximum expansion of the lungs.
10. Anurse is assessing an adult client who has been immobile for the past 3 weeks. The nurse should identify that which
of the following findings requires further intervention?

A. Erythema on pressure points

B. Lower-extremity pulse strength 2+
C. Fluid intake of 3,000 mL of fluid per day
D. A bowel movement every other day: A. Erythema on pressure points

Erythema on pressure points requires prompt relief of pressure and additional measure to protect the skin from further
breakdown

A pt should drink 2,500 to 3,000 mL of fluid per day

Bowel movement less frequent than three per week indicate constipation and the need for intervention

11. A
nurse is caring for a client who require a 24-hour urine collection. Which of the following statements by the client
indicates an understanding of the teaching?

A. "I had a bowel movement, but I was able to save the urine."
B. "I have a specimen in the bathroom from about 30 minutes ago."
C. "I flushed what I urinated at 7:00 a.m. and have save all urine since."
D. "I drink a lot, so I will fill up the bottle and complete the test quickly.": C. "I flushed what I urinated at 7:00 a.m. and
have save all urine since."

The pt should collect urine that is free of feces.

The pt should place any urine in the container immediately and keep it on ice or in a refrigerator.

The client should discard the first voiding and save all subsequent voidings.

There is not specified amount needed for a 24-hour urine collection.

12. Anurse is caring for a client who has herpes zoster and asks the nurse about the use of complementary and alternative
therapies for pain control. The nurse should inform the client that his condition is a contraindication for which of the
following therapies?

A. Biofeedback
B. Aloe
C. Feverfew
D. Acupuncture: D. Acupuncture

Acupuncture is contraindicated for a pt who has herpes zoster (aka shingles), or any skin infection, to prevent an open
portal on the skin's surface, which could increase the risk for further infection.

Feverfew is contraindicated in pts who are prescribed warfarin or other blood thinners.

13. Anurse is preparing to transfer a client who has right-sided weakness from the bed to a chair. In what order should the
nurse take the following actions to assist the client?: 1. Ask the client if he can bear weight
2. Position the chair on the left side of the bed
3. Have the client sit and dangle his feet at the bedside

4. Use the stand-and-pivot technique to move the client to the chair

14. A
nurse is preparing to administer an injection of an opioid medication to a client. The nurse draws out 1 mL of the
medication from a 2 mL vial. Which of the following actions should the nurse take?
A. Ask another nurse to observe the medication wastage
B. Notify the pharmacy when wasting the medication
C. Lock the remaining medication in the controlled substances cabinet
D. Dispose of the vial with the remaining medication in a sharps container: A. Ask another nurse to observe the
medication wastage

A second nurse must witness the disposal of any portion of a dose of a controlled substance

Pharmacies do not require notification of the disposal of a portion of a dose of a controlled substance

The nurse should not lock the remaining medication in the cabinet because this is a violation of the Controlled Substances
Act

The nurse should NOT dispose of the remaining medication in the sharps container because this is a violation of the
Controlled Substances Act

15. A
nurse is preparing a heparin infusion for a client who was hospitalized with deep-vein thrombosis. The order reads:
25,000 units of heparin in 250 mL of 0.9% sodium chloride to infuse at 800 units/hr. At what rate should the nurse set the
infusion pump? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing
zero.):

8 mL/hr

16. Anurse is caring for a client who has a prescription for 5 units of regular insulin and 10 units of NPH insulin to mix
together and administer subcutaneously. Determine the correct order of steps for this procedure.: 1. Inject 10 units of air
into the bottle of NPH insulin. CLOUDY.
2. Inject 5 units of air into the bottle of regular insulin. CLEAR.

3. Withdraw the correct dose of regular insulin from the bottle. CLEAR. 4. Withdraw the correct dose of NPH insulin from
the bottle. CLOUDY.

Cloudy insulin (NPH, Humulin N, Novolin N) should NOT enter clear insulin (regular, Humulin R, Novolin R) Inject air into
cloudy, Inject air into clear, Draw up clear, Draw up cloudy

------

Inject 10 units of air into the bottle of NPH insulin.

Inject 5 units of air into the bottle of regular insulin.
Withdraw the correct dose of regular insulin from the bottle.
Withdraw the correct dose of NPH insulin from the bottle.
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The nurse should first inject air into the vial of NPH without touching the needle to the solution. Next, the nurse should
inject air into the vial of regular insulin, and then withdraw the correct amount of the regular insulin. Finally, the nurse
should insert the needle into the NPH insulin vial and withdraw the correct amount of NPH insulin. The nurse should
follow these steps to prevent contaminating the regular insulin with NPH insulin.
17. A
nurse is caring for a client who is postoperative and refuses to use an incentive spirometer following major
abdominal surgery. Which of the following is the nurse's priority action?

A. Request that a respiratory therapist discuss the technique for incentive spirometry
B. Determine the reasons why the client is refusing to use the incentive spirometer
C. Document the client's refusal to participate in health restorative activities
D. Administer a pain medication to the client: B. Determine the reasons why the client is refusing to use the incentive
spirometer.

Assess first

18. Anurse is reviewing a client's medication prescription, which reads, "digoxin 0.25 by mouth every day." Which of the
following components of the prescription should the nurse question?

A. The medication
B. The route
C. The dose
D. The frequency: C. The dose

The dose is not complete. The number 0.25 should be followed by a unit of measurement, such as mg, to clarify the
amount the nurse should administer.

19. Anurse is caring for a client who has limited mobility in his lower extremities. Which of the following actions should
the nurse take to prevent skin breakdown?

A. Place the client in high-Fowler's position

B. Increase the client's intake of carbohydrates
C. Massage reddened areas with unscented lotion
D. Have the client use a trapeze bar when changing position: D. Have the client use a trapeze bar when changing position

By using a trapeze bar to assist with repositioning and transferring, the client avoids the friction and shearing that result
from sliding up and down in bed. Shearing is a risk factor for pressure-ulcer development.

20. A
nurse has accepted a verbal prescription for three tenths of a milligram of levothyroxine IV stat for a client who has
myxedema coma. How should the nurse transcribe the dosage of this medication in the client's medical record?

A. .3 mg
B. 0.3 mg
C. 0.30 mg
D. 3/10 mg: B. 0.3 mg

21. Anurse is caring for a client receiving fluid through a peripheral IV catheter. Which of the following findings at the IV
site should the nurse identify as infiltration?

A. Purulent exudate
B. Warmth
C. Skin blanching
D. Bleeding: C. Skin blanching

Skin blanching, edema, and coolness and the IV site indicate infiltration.

22. Anurse is preparing to administer multiple medications to a client who has an enteral feeding tube. Which of the
following actions should the nurse plan to take?

A. Dissolve each medication in 5 mL of sterile water

B. Draw up medications together in the same syringe
C. Push the syringe plunger gently when feeling resistance
D. Flush the tube with 15 mL of sterile water: D. Flush the tube with 15 mL of sterile water

When dissolving medications, the nurse should dissolve each medication in at least 30 mL of warm, sterile water

The nurse should draw up medications separately and not mix them together

If the nurse encounters resistance when administering medications, he should stop and contact the provider

The nurse should flush the feeding tube with 15 to 30 mL of sterile water before administration and between each
medication. The nurse should flush the feeding tube with 30 to 60 mL of sterile water following the administration of the
last medication

23. A
nurse is planning an education session for an older adult client who has just learned that she has type 2 diabetes
mellitus. Which of the following strategies should the nurse plan to use with this client?

A. Allow extra time for the client to respond to questions

B. Expect the client to have difficulty understanding the information
C. Avoid references to the client's past experiences
D. Keep the learning session in private and one-on-one: A. Allow extra time for the client to respond to questions

Older adult clients often process information at a slower rate than younger clients
The nurse SHOULD explore the client's past experiences and use them to establish connections to new knowledge

It is helpful when working with older adult clients to invite another household member to the teaching session so that
person can help reinforce new information later. The nurse, however, should honor the client's preference.

24. A
nurse is evaluating a client's use of a cane. Which of the following actions should the nurse identify as an indication of
correct use?

A. The top of the cane is parallel to the client's waist

B. When walking, the client moves the cane 46cm (18 in) forward
C. The client holds the cane on the stronger side of her body.
D. The client moves her stronger limb forward with the cane: C. The client holds the cane on the stronger side of her body.

The top of the cane should be parallel to the client's greater trochanter
To maintain balance, the client should advance the cane about 15 to 30 cm (6 to 12 in) at a time
The can should be held on the stronger side of the body to increase support and maintain alignment

The client should move her weaker leg forward with the cane. This divides the client's body weight between the cane and
the stronger leg

25. A
nurse is caring for a client who has had his diet prescription changed to a mechanical soft diet. Which of the following
food items should the nurse remove from the client's breakfast tray?

A. Tomato juice
B. Banana slices
C. Pancakes
D. Fried egg: D. Fried egg

Soft fruits, such as bananas or cooked fruits, are acceptable for a client who requires a mechanical soft diet

Evidence-based practice indicates the nurse should remove the fried eggs from the client's tray. Fried eggs are not a part
of a mechanical soft diet. Eggs that are poached or scrambled are an acceptable replacement for this item
26. A
nurse is caring for a client who asks about the purpose of advance directives. Which of the following statements
should the nurse make?

A. "They allow the court to overrule an adult client's refusal of medical treatment."
B. "They indicate the form of treatment the client is willing to accept in the event of serious illness."
C. "They permit a client to withhold medical information from health care personnel."
D. "They allow health care personnel in the emergency department to stabilize a client's condition.": B. "They indicate the
form of treatment the client is willing to accept in the event of serious illness."

27. A
nurse is assessing a client who has been on bed rest for the past month. Which of the following findings should the
nurse identify as an indication that the client has developed thrombophlebitis?

A. Bladder distention
B. Decreased blood pressure
C. Calf swelling
D. Diminished bowel sounds: C. Calf swelling

Swelling, redness, and tenderness in a calf muscle are manifestations of thrombophlebitis, a common complication of
immobility.

28. A
nurse is caring for a client who reports pain. When documenting the quality of the client's pain on an initial pain
assessment, the nurse should record which of the following client statements?

A. "I'm having mild pain."

B. "The pain is like a dull ache in my stomach."
C. "I notice that the pain gets worse after I eat."
D. "The pain makes me feel nauseous.": B. "The pain is like a dull ache in my stomach."

A. describes the severity of the pain

B. describes the quality of the the pain
C. describes a factor that aggravates the pain

29. A
nurse is administering an otic medication to an older adult client. Which of the following actions should the nurse
take to ensure that the medication reaches the inner ear?

A. Press gently on the tragus of the client's ear

B. Pack a small piece of cotton deep into the ear canal
C. Move the client's auricle down and back toward her head
D. Tilt the client's head back for 5 minutes: A. Press gently on the tragus of the client's ear

If cotton is necessary, the nurse should place it into the outer portion of the ear canal and not push it inward
For an adult client, the nurse should move the auricle upward and backward OR upward and outward to straighten the
ear canal The client should lie on her side with the ear that received the instillation facing upward for 2 to 5 minutes

30. A
nurse in a long-term care facility is planning to perform hygiene care for a new resident. Which of the following
assessment questions is the nurse's priority before beginning this procedure?

A. "When do you usually bathe, in the morning or in the evening?"

B. "Do you prefer a bath or a shower?"
C. "At what temperature do you prefer your bath water?"
D. "Are you able to help with your hygiene care?": D. "Are you able to help with your hygiene care?"

The greatest risk to the client's safety is an injury resulting from an overestimation of the client's ability to help with
hygiene care; therefore, the nurse's priority is to assess the client's ability to assist with her hygiene care
31. A
charge nurse is discussing the responsibility of nurses caring for clients who have a Clostridium difficile infection.
Which of the following information should the nurse include in the teaching?

A. Assign the client to a room with a negative air-flow system

B. Use alcohol-based hand sanitizer when leaving the client's room
C. Clean contaminated surface in the client's room with a phenol solution
D. Have family members wear a gown and gloves when visiting: D. Have family members wear a gown and gloves when
visiting

The nurse should use soap and water for hand hygiene because alcohol-based hand sanitizer does not kill Clostridium
difficile spores.

The nurse should use a phenol solution to clean surfaces contaminated with bacteria and fungi. However, it does not kill
Clostridium difficile spores.

32. A
nurse is assessing an older adult client's risk for falls. Which of the following assessments should the nurse use to
identify the client's safety needs? (Select all that apply.)

A. Lacrimal apparatus
B. Pupil clarity
C. Appearance of bulbar conjunctivae D. Visual fields
C. Visual acuity: B. Pupil clarity
D. Visual fields
C. Visual acuity

Cloudy pupils mean that the pt has cataracts, which can increase his risk for falls

Visual fields are tested by the use of a finger test by moving it out of range and then back into his visual field to determine
when he sees the finger

Visual acuity should be assessed using a Snellen chart

33. Anurse is caring for a client who is expressing anger over his diagnosis of colorectal cancer. Which of the following
actions should the nurse take?

A. Discuss the risk factors for colon cancer

B. Focus teaching on what the client will need to do in the future to manage his illness
C. Provide the client with written information about the phases of loss and grief
D. Reassure the client that this is an expected response to grief: D. Reassure the client that this is an expected response to
grief

During the anger stage of the client's psychosocial adaptation to illness, the nurse should support the client and ensure
him that this is an expected reaction to a cancer diagnosis

34. A
nurse is planning to insert a peripheral IV catheter for an older adult client. Which of the following actions should the
nurse plan to take?

A. Insert the catheter at a 45 degree angle

B. Place the client's arm in a dependent position
C. Shave excess hair from the insertion site
D. Initiate IV therapy in the veins of the hand: B. Place the client's arm in a dependent position

The nurse should insert the catheter at a 10 to 30 degree angle

The nurse should place the pt's arm in a dependent position because the veins will dilate due to gravity
The nurse should CLIP excess hair and AVOID shaving the area because shaving can cause breaks and cuts in the skin that
could place the client at risk for infection

The nurse should AVOID using the fragile veins of an older adult's hands because the loss of subcutaneous tissue makes
those veins roll away from the needle

35. Anurse is lifting a bedside cabinet to move it closer to a client who is sitting in a chair. To prevent self-injury, which of
the following actions should the nurse take when lifting the object?

A. Bend at the waist

B. Keep his feet close together
C. Use his back muscles for lifting
D. Stand close to the cabinet when lifting: D. Stand close to the cabinet when lifting

This action keeps the cabinet close to the nurse's center of gravity and decreases back strain from horizontal reaching
36. A nurse is providing care to four clients. Which of the following situations requires the nurse to complete an incident
report?

A. A nurse tied a client's restraint straps to the moveable part of the bed frame
B. An assistive personnel placed a surgical mask on a client who has tuberculosis before transporting her to radiology
C. A nurse administers a medication to a client 30 minutes before the dose is due
D. A client who has an IV infusion pump receives an additional 250 mL of IV fluid: D. A client who has an IV infusion pump
receives an additional 250 mL of IV fluid

The nurse should complete an incident report if an IV infusion pump malfunctions to assist in compiling information for
risk management to determine actions to take to prevent further medical incidents

37. Anurse manager is preparing to review medication documentation with a group of newly licensed nurses. Which of the
following statement should the nurse manager plan to include in the teaching?

A. "Use the complete name of the medication magnesium sulfate."

B. "Delete the space between the numerical dose and the unit of measure."
C. "Write the letter U when noting the dosage of insulin.:
D. "Use the abbreviation SC when indicting an injection.": A. "Use the complete name of the medication magnesium
sulfate."

The Institute for Safe Medication Practices designates that nurses and providers write the complete medication name
magnesium sulfate when documenting medications to avoid any misinterpretation of MgSO4 as MSO4, which means
morphine sulfate

38. Anurse in a surgical suite notes documentation on a client's medical record that he has a latex allergy. In preparation
for the client's medical record that he has a latex allergy. In preparation for the client's procedure, which of the following
precautions should the nurse take?

A. Ensure sterilization of non-disposable items with ethylene oxide

B. Wrap monitoring cords with stockinette and tape them in case
C. Cleanse latex ports on IV tubing with chlorhexidine before injecting medication
D. Wear hypoallergenic later gloves that contain powder: B. Wrap monitoring cords with stockinette and tape them in
place.

Many monitoring devices and cords contain latex. The nurse should prevent any contact of these cords and devices with
the client's skin by covering them with a nonlatex barrier material, such as stockinette, and using nonlatex tape to secure
them.

39. A
nurse is caring for a client who requires an NG tube for stomach decompression. Which of the following actions
should the nurse take when inserting the NG tube?
A. Position the client with the head of the bed elevated to 30 degrees prior to insertion of the NG tube
B. Remove the NG tube if the client begins to gag or choke
C. Apply suction to the NG tube prior to insertion
D. Have the client take sips of water to promote insertion of the NG tube into the esophagus: D. Have the client take sips of
water to promote insertion of the NG tube into the esophagus

The patient should be sitting in a high-Fowler's position with the head of the bed elevated to 90 degrees to reduce the risk
for aspiration

The nurse should withdraw the NG tube slightly, not remove it, when the client gags or chokes to reduce the risk of injury
to the client

Taking sips of water as the NG tube passes through the oropharynx will close the epiglottis over the trachea and prevent
the tube's passage into the trachea

40. Anurse is admitting a client who has an abdominal wound with a large amount of purulent drainage. Which of the
following types of transmission precautions should the nurse indicate?

A. Protective environment
B. Airborne precautions
C. Droplet precaution
D. Contact precautions: D. Contact precautions

Clients who have an immune-system compromise require a protective environment

Major wound infections require contact precautions, which mean the nurse should admit the client to a private room. All
caregivers should wear a gown and gloves during direct contact with this client

41. A
nurse is caring for a client who has a prescription for wound irrigation. Which of the following actions should the
nurse take?

A. Wear sterile gloves when removing the old dressing

B. Warm the irrigation solution to 40.5 degrees Celsius (105 degrees Fahrenheit)
C. Cleanse the wound from the center outward
D. Use a 20 mL syringe to irrigate the wound: C. Cleanse the wound from the center outward

The nurse should clean the wound from the center outward to prevent introduction of microorganisms from the outer
skin surface

42. Anurse is caring for a client who requires bed rest and has a prescription for antiembolic stockings. Which of the
following actions should the nurse take?

A. Apply the stockings so the creases are on the side of the leg
B. Apply the stockings while the client's legs are in a dependent position
C. Remove the stockings at least once per shift
D. Remove the stockings while the client is sitting in a reclining chair: C. Remove the stockings at least once per shift

The nurse should ensure there are no creases or wrinkles in the stockings to prevent skin irritation and promote venous
return

The nurse should apply the stockings in the morning before the client gets out of bed because the client's legs are less
edematous at that time

The nurse should remove the stocking once per shift to check the client's circulation and skin integrity
The client should wear the stockings while sitting in the chair to promote venous return. He should also avoid crossing his
legs
43. Anurse is caring for a client who has an NG tube and is receiving intermittent feedings through an open system. Which
of the following actions should the nurse take first?

A. Rinse the feeding bag with water between feedings

B. Tell the client to keep the head of the bed elevated at least 30 degrees
C. Make sure the enteral formula is at room temperature
D. Wipe the top of the formula can with alcohol: B. Tell the client to keep the head of the bed elevated at least 30 degrees

All of the actions are appropriate; HOWEVER, the first action the nurse should take when using the ABC approach to pt
care is to prevent aspiration of the enteral formula. This is done to prevent reflux of the formula backward into the
esophagus

44. A
nurse is caring for a client who has tuberculosis. Which of the following actions should the nurse take? (Select all that
apply.)

A. Place the client in a room with negative-pressure airflow B. Wear gloves when assisting the client with oral care
C. Limit each visitor to 2 hr increments
D. Wear a surgical mask when providing client care

E. Use antimicrobial sanitizer for hand hygiene: A. Place the client in a room with negative-pressure airflow B. Wear
gloves when assisting the client with oral care
E. Use antimicrobial sanitizer for hand hygiene

The nurse does NOT need to limit the client's visitors. However, the nurse should limit the client's presence outside the
room and have him wear a surgical mask when he does leave the room.

The nurse should wear an N95 respirator during client care to meet the requirements of airborne precautions

45. Anurse is responding to a call light and finds a client lying on the bathroom floor. Which of the following actions should
the nurse take first?

A. Check the client for injuries

B. Move hazardous objects away from the client
C. Notify the provider
D. Ask the client to describe how she felt prior to the fall: A. Check the client for injuries

46. Anurse is talking with the partner of an older adult male client who has dementia. The client's partner expresses
frustration about finding time to manage household responsibilities while caring for his partner. The nurse should
identify that he is going through which of the following types of role-performance stress?

A. Role ambiguity
B. Sick role
C. Role overload
D. Role conflict: C. Role overload

47. A
nurse is administering IV fluid to an older adult client. The nurse should perform which priority assessment to
monitor for adverse effects?

A. Auscultate lung sounds

B. Measure urine output
C. Monitor blood pressure readings
C. Monitor serum electrolyte levels: A. Auscultate lung sounds

All of the actions are appropriate; HOWEVER, the priority assessment the nurse should make when using the ABC
approach to client care is auscultating lung sounds to monitor for fluid-volume excess, a complication of IV therapy.
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The nurse should make when using the airway, breathing, circulation approach to client care is auscultating lung sounds
to monitor for fluid-volume excess, a complication of IV therapy. Manifestations of fluid volume excess include moist
crackles heard in lung fields, dyspnea, and shortness of breath.

48. Anurse if performing a peripheral vascular assessment for a client. When placing the bell of the stethoscope on the
client's neck, she hears the following sound. This sound indicates which of the following?

A. Narrowed arterial lumen

B. Distended jugular veins
C. Impaired ventricular contraction
D. Asynchronous closure of the aortic and pulmonic valves: A. Narrowed arterial lumen

Arterial bruits are blowing sounds resulting from blood flowing through occluded or narrowed arteries

49. A
nurse is completing an admission assessment for a client who reports vomiting and diarrhea for the past 3 days.
Which of the following assessment findings should the nurse expect?

A. Neck vein distention

B. Urine specific gravity 1.010
C. Rapid heart rate
D. Blood pressure 144/82 mmHg: C. Rapid heart rate

Tachycardia indicated fluid-volume deficit, which is an expected finding for a client who has had vomiting and diarrhea
for 3 days Neck vein distension is a clinical manifestation of fluid-volume excess
Typically, a client's urine specific gravity is greater than 1.030 in the presence of fluid-volume deficit
Hypotension is an expected finding for a client who has fluid-volume deficit

50. A
nurse is caring for a client who has terminal liver cancer. Which of the following statements should the nurse identify
as an indication that the client is experiencing spiritual distress?

A. "What could I have done to deserve this illness?"

B. "I blame medical science for not curing me."
C. "Where is my daughter at a time like this?"
D. "Will I ever begin to feel in charge of my life again?": A. "What could I have done to deserve this illness?"

51. Anurse is using an open irrigation technique to irrigate a client's indwelling urinary catheter. Which of the following
actions should the nurse take?

A. Place the client in a side-lying position

B. Instill 15 mL of irrigation fluid into the catheter with each flush
C. Subtract the amount of irrigant used from the client's urine output
D. Perform the irrigation using a 20 mL syringe: C. Subtract the amount of irrigant used from the client's urine output

For a catheter irrigation, the nurse should place the client in a supine or dorsal recumbent position for maximal access to
the catheter

Open irrigation technique requires instilling 30 to 40 mL or irrigation fluid.

The nurse should use a 30 to 50 mL syringe to perform open irrigation

52. Anurse is caring for a client who is refusing a blood transfusion for religious reasons. The client's partner wants the
client to have the blood transfusion. Which of the following actions should the nurse take?

A. Ask the client to consider a direct donation

B. Withhold the blood transfusion
C. Request a consultation with the ethics committee
D.. Ask the client's family to intervene: B. Withhold the blood transfusion

The principle of autonomy ensures that a client who is competent has the right to refuse treatment

53. A
nurse is reviewing a client's fluid and electrolyte status which of the following findings should the nurse report to the
provider?

A. BUN 15 mg/dL
B. Creatinine 0.8 mg/dL
C. Sodium 143 mEq/L
D. Potassium 5.4 mEq/L: D. Potassium 5.4 mEq/L

The value is above the expected reference range and the nurse should report this finding. The client is at risk for
dysrhythmias. Potassium: 3.5-5 mmol/L

54. A
nurse is admitting a client who has varicella. Which of the following types of transmission precautions should the
nurse initiate?

A. Airborne
B. Droplet
C. Contact
D. Protective environment: A. Airborne

Airborne precautions are a requirement for clients who have infections that spread via droplet nuclei that are smaller
than 5 microns in diameter, including varicella, tuberculosis, and measles

Contact precautions are needed for: VRE, MRSA, and scabies

Droplet precautions are needed for: rubella, meningococcal pneumonia, mumps, and streptococcal pharyngitis

55. A
nurse is caring for a client who is terminally ill. Which of the following statements should the nurse identify as an
indication that the client's family member is coping effectively with the situation?

A. "We are not worried. We still have hope that everything will be okay."
B. "This is a difficult time, but we are helping each other through this."
C. "After he comes home, we can plan our family reunion."
D. "We do not need to talk about funeral arrangements at this time.": B. "This is a difficult time, but we are helping each
other through this."

56. A
nurse is reviewing practice guidelines with a group of newly licensed nurses. Which of the following interventions
should the nurse include that is within the RN scope of practice?

A. Insert an implanted port

B. Close a laceration with sutures
C. Place an endotracheal tube
D. Initiate an enteral feeding through a gastrostomy tube: D. Initiate an enteral feeding through a gastrostomy tube

Nurses can initiate enteral feedings through nasoenteric, gastronomy, and jejunostomy tubes All other activities require a
physician or Advanced Practice Nurse (APN) to perform them

57. Anurse manager is overseeing the care on a unit. Which of the following situations should the nurse manager identify
as a violation of HIPPA guidelines?

A. A nurse who is caring for a client reviews the client's medical chart with the nursing student who is working with the
nurse B. A nurse asks a nurse from another unit to assist with her documentation
C. A nurse who is caring for a client returns a call to the client's durable power of attorney for health care designee to
discuss the client's care

D. A nurse discusses a client's status with the physical therapist that is caring for the client at the client's bedside: B. A
nurse asks a nurse from another unit to assist with her documentation

Only health care professionals directly caring for a client may access medical information; therefore, this is a violation of
HIPPA guidelines

58. A
nurse is reviewing protocol in preparation for suctioning secretions from a client who has a new tracheostomy.
Which of the following actions should the nurse plan to take?

A. Use a resuscitation bag with 80% oxygen prior to the procedure

B. Select a suction catheter that is half the size of the lumen
C. Place the end of the suction catheter in water-soluble lubricant
D. Adjust the wall suction apparatus to a pressure of 170 mmHg: B. Select a suction catheter that is half the size of the
lumen

The nurse should preoxygenate the client with 100% oxygen before suctioning to prevent hypoxemia.
The nurse should select a suction catheter that is half the size of the lumen to prevent hypoxemia and trauma to the
mucosa

the nurse should lubricate the end of the suction catheter with sterile water or 0.9% sodium chloride irrigation to
decrease trauma to the mucosa

The nurse should adjust the suction pressure to approximately 120 mmHg and no higher than 150 mmHg to prevent
hypoxemia and trauma to the mucosa.

59. A
nurse is performing a Romberg's test during the physical assessment of a client. Which of the following techniques
should the nurse use?

A. Touch the face with a cotton ball

B. Apply the vibrating tuning fork to the client's forehead
C. Have the client stand with her arms at her side and her feet together
D. Perform direct percussion over the area of the kidneys: C. Have the client stand with her arms at her side and her feet
together

Romberg's test helps identify alterations in balance. The nurse should have the client stand with her arms at her sides and
her feet together to observe her for swaying and a loss of balance.

60. A
nurse is preparing a change-of-shift report. Which of the following tools or documents should the nurse use to
communicate continuity of care?

A. Critical pathway
B. Situation, background, assessment, and recommendation (SBAR)
C. Transfer report
D. Medication administration record (MAR): B. Situation, background, assessment, and recommendation (SBAR)

A critical pathway is an interprofessional approach to planning all phases of client care.

The nurse should use a transfer report when the client is moving from one health care area or facility to another The
nurse should use the MAR to document medication administration