RN Fundamentals 2023

Question 3

A nurse is conducting the Weber’s test on a client. Which of the following is an appropriate action for the nurse to take?

Deliver a series of high-pitched sounds at random intervals.
Place an activated tuning fork in the middle of the client’s forehead.
Whisper a series of words softly into one ear.
Hold an activated tuning fork against the client’s mastoid process.

Question 4

A newly licensed nurse has forgotten their password and asks another nurse to access the computer system for them so they can document care before transferring the client to another unit. Which of the following responses should the nurse make?

“Provide the client’s information to the charge nurse, who can document the information for you.”
“Under these circumstances I can let you use my password just this one time.”
“I can give you the contact information for someone to assist you with recovering your password.”
“See the supervisor so they can give you a temporary password.”

Question 5

A nurse is caring for a client who has terminal cancer. The client tells the nurse, “I don’t want any more treatment; just make me comfortable.” The nurse should document that the client is in which of the following stages of grief?

Depression
Denial
Bargaining
Acceptance

Question 6

A nurse is planning care for a client who is scheduled for an intravenous pyelogram. Which of the following actions is appropriate for the nurse to include?

Ensure the client is free of metal objects.
Assist the client with a bowel cleansing.
Monitor the client for pain in the suprapubic region.
Administer 240 mL (8 oz) of oral contrast before the procedure.

Question 7

A nurse is caring for a client who states, “I smoke because I have a lot of anxiety.” The nurse should recognize the client’s statement as which of the following defense mechanisms?

Rationalization
Dissociation
Projection
Sublimation

Question 8

A nurse is caring for a client who reports that she has insomnia. Which of the following interventions is appropriate for the nurse to recommend?

Take a 30-min nap daily.
Exercise 1 hr before bedtime.
Drink a cup of hot cocoa before bedtime.
Eat a light carbohydrate snack before bedtime.

Question 9

A nurse is caring for an older adult client who has chronic pain related to peripheral neuropathy. Which of the following medications should the nurse expect the provider to prescribe for this client?

Cyclobenzaprine
Gabapentin
Oxycodone
Naproxen

Question 10

A nurse is teaching a client about meditation and progressive relaxation to reduce stress. Which of the following instructions should the nurse include?

Plan to meditate immediately after meals.
Keep eyes open during relaxation therapy.
Tighten and relax muscles during relaxation therapy.
Take short and shallow breaths when meditating.

Question 11

A nurse is caring for a client who has just died following unsuccessful CPR. The family wishes to view the body. Which of the following actions should the nurse take before inviting the family into the room?

Apply identification tags to the client’s extremities.
Leave resuscitation equipment and supplies at the bedside.
Hold the client’s eyelids closed until they remain shut.
Keep the head of the bed flat.

Question 12

A nurse is teaching a client about progressing from a clear liquid diet to a full liquid diet. Which of the following food selections by the client indicates an understanding of the teaching?

Pudding
Cooked vegetables
Yogurt with fruit
Bananas

Question 13

A nurse is planning care for a client who has contact precautions in place. Which of the following actions should the nurse plan to take when removing soiled linens from the client’s room?

Tie the linens’ bag securely at the top.
Wear sterile gloves when handling the linens.
Double-bag the linens.
Rinse the linens prior to removing them from the client’s room.

Question 14

A nurse is caring for a female client who is postoperative and is having difficulty urinating after the removal of an indwelling urinary catheter. Which of the following techniques should the nurse teach the client to use to promote urination?

Performing Kegel exercises prior to urination
Pouring warm water over the perineum
Stroking the lower abdomen
Leaning backward when sitting and attempting to urinate

Question 15

A nurse is caring for a client who was administered more than the prescribed dose of a medication. Which of the following actions should the nurse take first?

Educate the client about potential adverse effects.
Obtain the client’s vital signs.
Complete an incident report.
Notify the primary care provider.

Question 16

A nurse is using the domains of learning to provide teaching to a client who has diabetes mellitus. Which of the following actions should the nurse take to utilize psychomotor learning?

Observe the client practice self-monitoring of blood glucose levels.
Ask the client to attend a class about following a diabetic diet.
Show the client a video about self-administration of insulin.
Assist the client in discussing their feelings about having diabetes mellitus.

Question 17

A nurse enters a client’s room to perform a focused assessment. Which of the following client information should the nurse use to properly identify the client?

Provider’s name
Diagnosis
Room number
Telephone number

Question 18

A nurse is providing discharge teaching for a client who will be receiving oxygen therapy at home. Which of the following instructions should the nurse include in the teaching?

“You should purchase a fire extinguisher for your home.”
“You will no longer be able to use an electric razor.”
“Family members who smoke must do so at least 6 feet away from the oxygen tank.”
“You should use woolen blankets on your bed.”

Question 19

A nurse is preparing to administer a medication to a client for the first time. Which of the following actions should the nurse take to help ensure safe medication administration?

Ask the client if they have ever taken a similar medication.
Access the online drug formulary for an unfamiliar medication.
Read the medication label twice prior to administration.
Use one patient identifier prior to medication administration.

Question 20

A nurse is evaluating a newly licensed nurse’s understanding of advance directives. The newly licensed nurse should identify that which of the following individuals is responsible for deciding whether a client is capable of making their own decisions regarding medical treatment?

Social worker
Health care surrogate
Primary provider
Charge nurse

Question 21

A nurse is preparing to administer an intramuscular injection to a client. Which of the following actions should the nurse take?

Select the ventrogluteal site for an injection volume greater than 2 mL.
Use a 25-gauge needle to administer the medication.
Aspirate for blood return prior to injecting the medication.
Insert the needle at a 45° angle.

Question 22

A nurse is caring for a client who has a prescription for a 24-hr urine collection. Which of the following actions should the nurse take?

Discard the first voiding when beginning the collection period.
Store the urine in a clear container at the bedside.
Include the first voiding from the following morning in the collection.
Restart the collection if the client voids without saving the specimen.

Question 23

RN Fundamentals 2023. A nurse is planning care for a client who reports insomnia. Which of the following actions should the nurse perform shortly before bedtime?

Provide a late supper.
Prepare hot cocoa or tea for the client.
Offer a wet washcloth for the client to wash their face.
Perform range-of-motion exercises.

Question 24

A nurse is caring for a client who is postoperative and is receiving opioid analgesics. Which of the following findings should the nurse report to the provider?

BP 130/84 mm Hg
Heart rate 88/min
Respiratory rate 10/min
Oral temperature 37.4° C (99.3° F)

Question 25

A nurse is planning care for a client who has a newly placed percutaneous endoscopic gastrostomy (PEG) tube and is agitated and confused. The provider prescribes bilateral wrist restraints. Which of the following actions should the nurse plan to take?

Place the client in a supine position.
Attach the straps to the side rails of the bed frame.
Remove the restraints every 2 hr.
Secure the straps with a square knot.

Question 26

A nurse is providing teaching to a client who is anxious about their mastectomy scheduled in 2 hr. Which of the following complementary therapies should the nurse recommend to the client?

Herbal medicine
Magnet therapy
Guided imagery
Acupuncture

Question 27

A nurse is caring for a postoperative client. Which of the following findings indicate the client may be actively bleeding?

Brisk capillary refill
Bounding pulses
Restlessness
Warm skin

Question 28

A nurse is preparing to administer an intradermal tuberculin test to a client. Which of the following actions should the nurse take?

Point the bevel of the needle upward prior to insertion.
Insert the needle at a 20° angle to the client’s skin.
Advance the needle 6 mm (1/4 in) below the skin’s surface.
Administer the injection on the dorsal forearm. RN Fundamentals 2023

Question 29

A nurse in an urgent care center is caring for a young adult client who requires suturing of a laceration. The client tells the nurse, “My family should have been here by now. I can’t go through this without them.” Which of the following responses should the nurse make? RN Fundamentals 2023

“You’ll feel better once this procedure is over.”
“I will be available for you until your family arrives.”
“I’m sure your family will be here soon.”
“Why do you think your family is delayed?”

Question 30

A charge nurse is providing an in-service to a group of nurses about the components of informed consent. Which of the following information should the nurse include? RN Fundamentals 2023

The provider obtains verbal consent for the procedure without witnessing the client’s signature.
Clients are unable to change their mind once a consent form is signed.
The nurse’s role is to provide the client with initial information about the procedure prior to obtaining informed consent.
The provider performing the procedure is responsible for obtaining informed consent.

Question 31

A nurse is conducting an in-service for staff members about the Emergency Medical Treatment and Active Labor Act. Which of the following statements by a staff member indicates an understanding of this act?

“A client can be discharged to another facility when their condition stabilizes.”
“A client can be discharged to another facility if they are unable to pay for services received.”
“A client can be discharged to another facility if their behavior is unsafe and inappropriate.”
“A client can be discharged to another facility if their condition is terminal.”

Question 32

A nurse receives a telephone prescription from a provider for a client who is experiencing pain. Which of the following responses should the nurse make?

“I will sign my name now and leave a space for you to sign your name.”
“Will you please spell the name of that medication for me?”
“Let me provide you with the client’s medical record number for identification.”
“Let me clarify that you want the medication given qid, correct?”

Question 33

A nurse is caring for a client who is immobile. Which of the following interventions should the nurse plan to take to prevent plantar flexion contractures? RN Fundamentals 2023

Apply an abduction pillow to the legs.
Use a trochanter roll.
Use foot splints.
Prop the feet up.

Question 34

A nurse is caring for a client who is receiving enteral feedings through a nasogastric tube and has developed diarrhea. Which of the following actions should the nurse take?

Add yogurt to enteral feedings.
Slow down the instillation flow rate.
Add water during tube flushes.
Change to an enteral formula that has added fiber.

Question 36

A nurse is evaluating an assistive personnel (AP) who is changing a client’s bed linens. Which of the following actions by the AP demonstrates medical asepsis?

Puts unneeded clean linens in the hamper.
Places soiled linens on the floor.
Holds linens close to the body.
Shakes soiled linens before placing them in the hamper.

Question 37

A nurse is caring for a client who is receiving intravenous fluids. The nurse notes the client’s skin around their peripheral IV site is taut and edematous. Which of the following complications is the client experiencing?

Infiltration
Phlebitis
Infection
Air embolism

Question 38

A nurse is planning teaching for a client who will be discharged with a central venous access device. Which of the following actions should the nurse plan to take first?

Obtain written information to give the client.
Make a priority list of information the client should learn.
Select a visual method to reinforce verbal teaching for the client.
Determine the client’s learning needs.

Question 39

A nurse is reviewing the prescriptions for a client who is experiencing dysphagia following a stroke. Which of the following prescriptions should the nurse clarify?

Speech therapy referral
Clear liquids
Dietitian consult
Oral suction at the bedside

Question 40

A nurse is preparing to remove an indwelling urinary catheter from a client. In what order should the nurse perform the following steps? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Don clean gloves.
Attach the syringe to the balloon injection port.
Withdraw the solution from the balloon.
Slowly pull the catheter out of urethral canal.
Dry the perineal area.

Question 42

A nurse is teaching a group of newly licensed nurses about the Braden scale. Which of the following responses by a newly licensed nurse indicates an understanding of the teaching?

“The client’s age is part of the measurement.”
“The higher the score, the higher the pressure injury risk.”
“The scale measures six elements.”
“Each element has a range from one to five points.”

Question 51

A nurse is caring for a client following bilateral knee replacement surgery and they require assistance with dressing. The nurse should report this information to which of the following interdisciplinary team members?

Physical therapist
Occupational therapist
Social worker
Respiratory therapist

Question 52

A nurse is providing a handoff report to the oncoming shift nurse. Which of the following actions should the nurse take to ensure continuity of client care?

Use a standardized approach to giving the handoff report.
Provide the handoff report at the nurses’ station.
Record a verbal report on a recorder for the oncoming nurse to listen to.
Encourage the oncoming shift nurse to contact the provider with any questions.

Question 53

A nurse is teaching a client how to self-administer daily low-dose heparin injections. Which of the following factors is most likely to increase the client’s motivation to learn?

The nurse explaining the need for education to the client
The client’s belief that his needs will be met through education
The nurse’s empathy about the client having to self-inject
The client seeking family approval by agreeing to a teaching plan

Question 54

A nurse is completing discharge teaching about ostomy care with a client who has a new stoma. Which of the following instructions should the nurse include in the teaching? (Select all that apply.)

Use povidone-iodine to clean around the stoma.
Empty the ostomy pouch when it becomes one-third full of contents.
Cut the opening of the pouch 1/8 of an inch larger than the stoma.
Expect the stoma to turn a purple-blue color as it heals.
Place a piece of gauze over the stoma while changing the pouch.

Question 55

A nurse is caring for a client who is immobile and developing skin breakdown. Which of the following actions should the nurse take? RN Fundamentals 2023

Keep the head of the client’s bed at 30° or less.
Slide the client up in bed every 2 hr.
Bathe the client with soap and hot water.
Massage bony prominences four times daily.

Question 56

A nurse is planning care for a client who has a new prescription for parenteral nutrition (PN) in 20% dextrose and fat emulsions. Which of the following is an appropriate action to include in the plan of care?

Change the PN infusion bag every 48 hr.
Administer the PN and fat emulsion separately.
Obtain a random blood glucose daily.
Prepare the client for a central venous line.

Question 57

A nurse in an outpatient clinic is caring for a client. Which of the following findings indicates the client is experiencing a hearing deficit?

No response to tactile stimuli
Persistent repositioning of objects
Decreased attention span
Presence of expressive aphasia

Question 58

A nurse is caring for a client who is experiencing a tonic-clonic seizure. Which of the following actions should the nurse take?

Monitor the client’s respiratory and cardiac status.
Place the client in a supine position during the seizure.
Use a padded tongue blade to protect the client’s tongue while seizing.
Offer the client a cup of juice to drink once the seizure is over.

Question 59

A nurse in an emergency department is assessing a client who reports right lower quadrant pain, nausea, and vomiting for the past 48 hr. Which of the following actions should the nurse take first?

Offer pain medication.
Administer an antiemetic.
Auscultate bowel sounds.
Palpate the abdomen.

Question 60

A nurse is discussing expected changes associated with aging with an older adult client. Which of the following client statements should indicate to the nurse that the client has an impaired body image?

“My hearing has improved since I got my hearing aids.”
“I avoid going out because I sometimes have problems with incontinence.”
“These lines in my face reveal a part of my character.”
“My wrinkled hands show how hard I’ve worked all my life.”

Question 61

A nurse is caring for a client who has hypocalcemia. Which of the following findings should the nurse expect?

Lethargy
Positive Chvostek’s sign
Constipation
Muscle flaccidity

Question 62

A nurse is providing teaching for a client who has a recent diagnosis of type 2 diabetes mellitus. Which of the following information should the nurse prioritize in the teaching for a diabetic diet?

“You should follow a diet high in vegetables, fiber, and uncooked fruit.”
“You should follow a low cholesterol diet.”
“You should follow a balanced intake of carbohydrates, fats, and proteins.”
“You should follow a low sodium diet.”

Question 63

A nurse is caring for a client who is 4 hr postoperative following abdominal surgery. Which of the following findings should the nurse report to the provider?

Urine output 25 mL/hr
Heart rate 68/min
Serosanguineous drainage on surgical dressing
Hypoactive bowel sounds

Question 64

A nurse is caring for a client on a medical-surgical unit. Which of the following actions are part of the isolation precautions for this client? Select all that apply.

When removing personal protective equipment, remove gloves first.
Place the client in a room with positive air flow.
Provide a mask for the client when they are outside their room.
Don a gown when entering the client’s room.
Perform hand hygiene with at least 4 to 5 mL of hand sanitizer when leaving the client’s room.

Question 65

Drag words from the choices below to fill in each blank in the following sentence. The nurse should first follow up on the client’s oxygen saturation and behavioral findings.

oxygen saturation
pain
WBC count
behavioral findings
bowel findings

Question 66

Complete the following sentence by using the lists of options. At 1000, the nurse enters the client’s room. The first action the nurse should take is to note the time followed by turn the patient on their side.

document the seizure event
note the time
turn the patient on their side

Question 67

Drag words from the choices below to fill in each blank in the following sentence. Based on the client’s manifestations, they developed infection and phlebitis. RN Fundamentals 2023

extravasation
infiltration
thrombophlebitis
infection
circulatory overload
phlebitis

RN Fundamentals 2023

Isaura K

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