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FUNDAMENTALS

1. The nurse performing the Rinne test during a physical examination expects to
gather data that could support which nursing diagnosis?
A. Impaired physical mobility
B. Impaired thought processes
C. Impaired swallowing
D. Altered sensory/perception: auditory
The Rinne test involves the examiner using a tuning fork to compare air
conduction to bone conduction related to transmission of sound.
2. The nurse is passing medications in the day room of a long-term care facility.
What is the best technique for the nurse to use to prevent medication error when
passing medications?
A. Checking the identification bracelet and ask the client to state name
and date of birth.
To prevent medication errors, the nurse should ensure administrations to the
right client by checking an ID band and asking the client to state name and
date of birth. This method ensures that two unique identifiers are used for
each client.
B. Ask each client her first and last name.
C. Pass the medication in alphabetical order.
D. Give all oral medications first, and then give inhalers or injections.
3. A client with acquired immunodeficiency syndrome (AIDS) who has Pneumocystis
carinii is being admitted to the nursing unit. The nurse should institute which of
the following?
A. Standard precautions
Standard precautions are used with all clients, regardless of the medical
diagnosis. Clients with AIDS or Pneumocystis carinii pneumonia are not
contagious and do not require transmission-based precautions.
B. Airborne precautions
C. Droplet precautions
D. Contact precautions
4. The nurse has applied elbow splints on a confused client to prevent the client
from removing the intravenous (IV) line. Which of the following interventions is
required?
A. Document appearance of clients IV site every hour
B. Remove elbow splints every 8 hours
C. Ask for renewal of physicians restraint order every 72 hours
D. Assess and document clients condition at least every hour
The client should be checked at least hourly, and the nurse must document
client status.
5. The nurse is changing the dressing of a client who is 4 days postoperative with
an abdominal wound. The nurse has changed this dressing daily since surgery.
Today, the nurse notes increased serosanguineous drainage, wound edges not
approximated, and puffy tissue protruding through the wound. The nurse
concludes which of the following conditions exists?

A.
B.
C.
D.

Hemorrhage
Normal healing by primary intention
Normal healing by secondary intention
Evisceration
Evisceration occurs when internal viscera protrude from an incision that is
dehiscing. In this situation, the nurse notes changes in wound appearance
such as increased serosanguineous drainage, edges lacking approximation,
and the protruding viscera.

6. Which statement heard by a nurse during intershift report provides the most
useful information related to priority setting for the upcoming shift?
A. Client who had catheter removed 8 hours ago has not urinated
A client who has not urinated following catheter removal would require
nursing intervention, specifically an assessment of the clients abdominal
distention, reviewing intake and output records, and possibly calling the
physician for an order to do a straight catheterization.
B. Client who is alert and oriented to person and place
C. Client who is 3 days postoperative is experiencing incisional pain
D. Client admitted congestive heart failure has a blood pressure of 138/80
7. The nurse would formulate which of the following as the most appropriate goal
for the client with droplet precautions?
A. The client will identify three ways to reduce the spread of infection.
Identifying three ways to reduce the spread of infection is the only goal that
is client-focused, specific, and measurable. The verbs limit and understand
are too vague to be measurable, and the words to be taught are focused on a
nursing goal, not a client goal.
B. The client will limit the risk of exposure to the causative agent.
C. The client will be taught how to take antimicrobial medication.
D. The client will understand how to protect other family members.
8. A nurse has selected a transparent film dressing for a stage 2 pressure ulcer.
How often will the nurse change the dressing?
A. Every 8 hours
B. When there is a change in color
C. Every 72 hours
D. When the edges roll up and exudate leaks
Transparent film dressings on a clean, non-infected wound can be left in place
for days, until the seal is broken, exudate leaks out, or the edges roll up.
Older adults are at risk for skin breakdown. A nurse needs knowledge of what
dressings are chosen and when they are changed.
9. A client who has been admitted with a drug overdose has become combative.
Which written physician order should the nurse question?
A. Restrain for agitation and PRN.
There can be no PRN order for a restraint. A restraint order must include the
reason for the restraint, type of restraint, and a time to use the restraint.
B. Restrain limbs for combative behavior assess hourly.
C. May use vest restraint until less combative or until morning.
D. May restrain for anxiety re-evaluate q 2 hours after medication administered.

10.The postoperative client questions why the nurse encourages repositioning from
side to side at least once every two hours. The nurse explains this intervention is
to achieve which of the following?
A. Aids return of peristalsis at a faster rate
B. Lessens muscle weakness
C. Increases the clients ability to sleep
D. Lets the lungs alternately achieve maximum expansion
Turning side-to-side allows the lungs alternately to expand properly.
11.A client on the unit has fallen trying to get from the bed to the chair. What is the
primary intervention by the nurse?
A. Notify the health care provider.
B. Identify and question witnesses.
C. Assess the client for injury.
The primary intervention in an accident is to assess for injury and provide
urgent care. Client safety is always first.
D. Ask the client the reason for trying to get out of bed.
12.Which statement made during a client interview represents a value judgment by
the nurse?
A. I think your weight loss of 50 pounds was beneficial to your health.
B. Why did you decide to stop taking your blood pressure pill?
C. Can you tell me how many alcoholic drinks you have each night?
D. How can you afford to smoke if youre currently unemployed?
How a client spends income, even on an unhealthy habit, is not necessary for
the nurse to know in order to provide effective care; the statement represents
a value judgment on the part of the nurse.
13.A nurse has received a report on a client being admitted with anemia who
requires a blood transfusion. The nurse will anticipate which assessment
findings?
A. Tachycardia
B. Hypertension
C. Headache
D. Diaphoresis
E. Bounding peripheral pulses
Key features of anemia include coolness to touch, intolerance to cold,
tachycardia, orthostatic hypotension, and headache.
14.Which teaching strategy should the nurse choose as being most likely to be
effective when providing health instruction to an adolescent client?
A. Lecture format
B. Professionally made videos
C. Client contracting
Client contracting provides adolescents with the ability to be involved in their
care. Adolescents should be involved in planning and decision making
regarding their need for information about their own health issues.
D. Role-play

15.When the staff nurse asks questions about the preoperative clients vision and
hearing, a family member asks the nurse why the questions are important. What
information should the nurse provide as the primary reason for seeking this
information?
A. This will help us determine the need for additional resources after
discharge.
B. This will help assess the risk of accidents in the home after surgery, which
could affect the surgical outcome.
C. This helps identify any unanticipated needs prior to beginning the surgery.
D. This will help us to individualize how we provide preoperative and
postoperative teaching.
The ability of the client to see and hear could affect the preoperative and
postoperative teaching methods used.
16.While performing an environmental assessment of a 72-year-old client, what
hazards should the nurse document and correct?
A. Absence of grab bars in the bathroom, and unanchored rugs
Older adults are at risk for falls. Lack of grab bars and the presence of throw
rugs pose a threat for falls.
B. Non-skid tub and shower mats
C. Smoke detectors and fire extinguishers
D. Night lights in bathrooms and hallways
17.A male nurse needs to check the vital signs and oxygen saturation level of a
female client from a different culture. As the nurse approaches, the client moves
to the other side of the bed and draws up the blanket. What is the best nursing
action at this time?
A. Invite a family member to be present and to assist with the oxygen saturation
reading.
B. Ask a female nurse to perform the procedures.
C. Perform the assessments without acknowledging her reaction because she
will adjust over time to hospital procedures.
D. Before touching the client, explain the procedure and ask for
permission to continue.
The response that shows cultural sensitivity is one that respects the personal
boundaries for the client and asks permission to engage in care activities.
18.A postoperative client tells the nurse that he developed dehiscence after his last
surgery and wants to make sure it doesnt happen this time. In attempting to
prevent dehiscence from occurring, the nurses interventions would be aimed at
doing which of the following?
A. Helping the client lose weight
B. Preventing vomiting
Activities that are likely to lead to dehiscence include vomiting and coughing
because they increase intra-abdominal pressure.
C. Administering antibiotics
D. Keeping the wound dry
19.When evaluating the effectiveness of a restraint, it is most important for the
nurse to document which item?

A.
B.
C.
D.

Behavior and response of the clients family to the restraint


Exact time the restraint is removed
Nurses interactions with the client while the client is in the restraint
Clients behavior while in the restraint
It is imperative for the nurse to assess and document the clients behavior
while the client is in restraints. This will help to determine whether the client
has a continued need for restraints.

20.A client reports inability to sleep through the night since admission 3 days ago.
Which of the following factors is most likely to negatively affect the clients sleep
patterns?
A. Presence of pain
Pain can often interfere with sleep.
B. Absence of unfamiliar stimuli
C. Ability to talk about days events
D. Moderate fatigue
21.A 25-year-old female presents to the office with complaints of burning,
frequency, and urgency with voiding. What is the most appropriate intervention
by the nurse?
A. Try to increase the clients fluid intake.
B. Test the urine for leukocytes using dipstick method.
C. Obtain an order for phenazopyridine (Pyridium).
D. Obtain an order for an antibiotic.
22.Each of the following clients will be having surgery this morning. The nurse
concludes that which client is most likely to be at higher overall surgical risk?
A. A client who has dementia
B. A client who is culturally different than the medical personnel
C. A client who has mild anxiety
D. A client who has had previous surgeries
23.The Emergency Department nurse is assigned to the trauma room upon the
arrival of several victims of a motor crash. The nurse would first conduct a
primary survey in triaging the accident victims in order to identify which of the
following?
A. Victims at risk for shock
B. Severity of injuries of all clients
C. Accident victims and family members
D. Life-threatening conditions
The purpose of triage is to sort accident victims for the purpose of treatment.
The focus of the primary survey is to identify victims the life-threatening
injuries and send these victims for priority treatment.
24.By ensuring the clients health record is not open in the nurses station, the
nurse assures the client of which of the following?
A. Privacy
Clients must be assured the right of privacy because they disclose sensitive
and personal information. Ensuring that the medical record is not visible to
others help achieve that right.

B. Beneficence
C. Disclosure
D. Anonymity
25.An insurance company has requested a copy of a clients chart from the
physicians office to compensate the physician for medical care received by the
client. What is the most appropriate action by the office nurse?
A. Tell physician of the insurance companys request
B. Copy clients record and send it to the insurance company
C. Refer insurance company to the office manager
D. Explain that the clients medical record is confidential
All information in the clients record is confidential and access to the record is
restricted unless the client has given permission for release.
26.

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