Question 1 of 70
RN Fundamentals 2023. A nurse is caring for a client. The nurse is reviewing the client’s medical record. Select the 3 findings that require immediate follow-up.
Case Study Summary:
On Day 1, the client is receiving IV Lactated Ringer’s at $100\text{ mL/hr}$ and weighs $75\text{ kg}$. By Day 2, the client’s weight increased to $77\text{ kg}$, they developed bilateral crackles in the lungs, $2+$ pitting ankle edema, and distended neck veins, indicating fluid volume overload.
- IV site
- Ankle edema
- Breath sounds
- Temperature
- Weight gain
Question 2 of 70
A nurse is caring for a client who has an ileostomy. The nurse is reviewing the client’s medical record. Click to highlight the information that requires intervention by the nurse. To deselect information, click on the information again.
Case Study Summary: RN Fundamentals 2023
On Day 1, the client with a new ileostomy is alert but refuses to look at or participate in stoma care. On Day 2, the skin surrounding the stoma is reddened and irritated, and the 24-hour urine output has dropped significantly from 1,200 mL to 650 mL despite an intake of 1,600 mL
- Ileostomy stoma is pink.
- Stoma draining moderate brown liquid stool.
- Client will not look at the stoma.
- Client states they are not interested in learning about stoma care.
- Intake: 2,200 mL over the last 24 hr
- Skin surrounding the stoma is reddened and appears irritated.
- Urine output: 650 mL over the last 24 hr
Question 3 of 70
A nurse is reviewing the medical record of a client. Complete the following sentence by using the lists of options.
Case Study Summary:
The client has a history of Parkinson’s disease and presents with a hoarse voice and coughing while eating. A swallowing exam confirmed an upper gastrointestinal mobility disorder, and by Day 2, the client’s respiratory rate and heart rate increased, with oxygen saturation dropping to $94\%$.
The client is at risk for developing aspiration due to dysphagia.
- Aspiration
- Fluid volume deficit
- Pressure injury
- Dysphagia
- Urinary retention
- Disuse syndrome
Question 4 of 70
A nurse is reviewing the medical record of a client. Which of the following findings place the client at risk for osteoporosis? Select all that apply.
Case Study Summary:
The client reports a sedentary lifestyle and lactose intolerance, leading to low dietary calcium. Lab results show a decline in Vitamin D levels from $24\text{ ng/dL}$ to $15\text{ ng/dL}$, which is significantly below the normal reference range.
- Activity level
- Vitamin D level
- Phosphorous level
- Lactose intolerant
- Alcohol use
- Smoking history
Question 5 of 70
A nurse is caring for a client. The nurse is reviewing the client’s medical record. Which of the following actions should the nurse take? Select all that apply.
Case Study Summary:
The client is allergic to penicillin but was prescribed Amoxicillin. The client reports persistent nausea and develops new-onset diarrhea (three loose stools) and abdominal cramping on Day 3, suggesting a potential C. difficile infection.
- Request a prescription for an antiemetic medication.
- Clarify the prescription for amoxicillin with the provider.
- Place the client on contact precautions.
- Hold the client’s levothyroxine.
- Wear a surgical mask when providing care.
- Request a prescription to increase the client’s metoprolol.
Question 6 of 70
The nurse should first address the client’s risk for developing pressure injury as evidenced by the client’s:
- decreased bowel sounds
- breath sounds
- prealbumin level
Question 7 of 70
A nurse is caring for a client who has a new diagnosis of fibromyalgia. The client tells the nurse that she wants to use traditional Chinese medicine for treatment instead of the medication prescribed by their provider. Which of the following is an appropriate response by the nurse?
- “You should try the prescribed medication before choosing an alternative.”
- “You should ask your provider if she recommends traditional Chinese medicine.”
- “I can arrange a referral to a practitioner of traditional Chinese medicine.”
- “The FDA regulates traditional Chinese medicine.”
Question 8 of 70
A nurse is caring for a client who has a new diagnosis of insulin-dependent diabetes mellitus. The client states, “I am concerned about being able to monitor my blood glucose regularly due to my busy schedule.” Which of the following responses should the nurse make?
- “You should be fine as long as you check your blood glucose before eating.”
- “Your provider will set up a schedule for when you should monitor your blood glucose.”
- “We can discuss several scheduling options for monitoring your blood glucose.”
- “You should reorganize your schedule around your blood glucose monitoring.”
Question 9 of 70
A nurse is assessing a client who has chronic pain. The nurse should identify that which of the following findings is associated with chronic pain?
- Depression
- Diaphoresis
- Constricted pupils
- Bradycardia
Question 10 of 70
A nurse is preparing to lift a box of personal items off the floor in a client’s room. Which of the following actions should the nurse take to help prevent injury when lifting the box?
- Bend at the waist to pick up the box.
- When lifting the box, keep the feet close together.
- Relax the abdominal muscles to prevent straining the back.
- When lifting the box, keep it close to the body.
Question 11 of 70
A nurse is conducting a health assessment for a client who takes herbal supplements. Which of the following statements by the client indicates an understanding of the use of the supplements?
- “I take ginkgo biloba for a headache.”
- “I take echinacea to control my cholesterol.”
- “I use garlic for my menopausal symptoms.”
- “I use ginger when I get car sick.”
Question 12 of 70
A nurse on a medical-surgical unit is receiving a change-of-shift report for four clients. Which of the following clients should the nurse see first?
- A client who has new onset of dyspnea 24 hr after a total hip arthroplasty
- A client who has a urinary tract infection and low-grade fever
- A client who has acute abdominal pain of 4 on a scale from 0 to 10
- A client who has pneumonia and an oxygen saturation of 96%
Question 13 of 70
A nurse is caring for a client who has dysphagia. When assisting the client during breakfast, which of the following actions by the client indicates the nurse should intervene?
- The client adjusts the head of their bed to 90°.
- The client drinks their thickened juice with a straw.
- The client takes frequent breaks while eating.
- The client tucks their chin when they swallow.
Question 14 of 70
A nurse is assessing a client whose therapy has included bed rest for several weeks. Which of the following findings should the nurse identify as the priority?
- Increased heart rate during physical activity
- Loss of appetite
- Musculoskeletal weakness
- Left lower extremity tenderness
Question 15 of 70
A nurse is assessing a client’s cranial nerve VII. Which of the following responses should the nurse expect?
- The client has a symmetrical smile.
- The client’s tongue is in a midline position.
- The client turns their head against resistance.
- The client’s pupils constrict in response to light.
Question 16 of 70
A nurse is assessing a client who has hypocalcemia. Which of the following findings should the nurse expect? (Select all that apply.) RN Fundamentals 2023f
- Muscle cramps
- Abdominal distention
- Negative Chvostek’s sign
- Tingling sensation around the lips
- Positive Trousseau’s sign RN Fundamentals 2023
Question 17 of 70
A nurse is teaching a client about stress management techniques. Which of the following client statements indicates an understanding of the teaching?
- “I should exercise for 1 hour each week.”
- “I should do tasks myself, rather than delegate.”
- “I should attend a support group each week.”
- “I should go to bed at a different time each night.”
Question 18 of 70
A nurse is caring for a postoperative client. Which of the following findings indicate the client may be actively bleeding?
- Restlessness
- Warm skin
- Bounding pulses
- Brisk capillary refill
Question 19 of 70
A nurse is teaching a class about the guidelines for the standards of care for nursing. Which of the following defines the nursing scope of practice?
- State-based Nurse Practice Acts
- The Joint Commission
- National League for Nursing
- Patients’ Bill of Rights
Question 20 of 70
A home health nurse is providing teaching about home safety to an older adult client. Which of the following examples of home safety should the nurse include in the teaching?
- Obtain a raised toilet seat for the bathroom.
- Cover slippery stairs with an area rug.
- Secure loose wires under carpeting.
- Use extension cords to prevent overloading circuits.
Question 21 of 70
A nurse is assessing a client’s abdomen. In what order should the nurse complete the steps of the assessment? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)
- Observe the contours of the client’s abdomen using a penlight.
- Determine the presence of bowel sounds by using the diaphragm of the stethoscope.
- Systematically percuss the client’s abdomen.
- Use fingertips to lightly depress the right lower quadrant of the client’s abdomen.
- Press deeply into the client’s upper abdomen left of midline to detect aortic pulsation.
Question 20
A nurse is assessing a client’s risk for developing a pressure injury. Which of the following findings should the nurse identify as a risk factor?
- Albumin level 3.0 g/dL
- Hemoglobin level 14 g/dL
- BMI of 24
- Braden scale score of 20
Question 21
A nurse is preparing to administer an enteral feeding to a client via a nasogastric (NG) tube. Which of the following actions should the nurse take?
- Verify the placement of the NG tube by aspirating gastric contents.
- Warm the formula in a microwave prior to administration.
- Place the client in a supine position during the feeding.
- Flush the tube with 10 mL of water before and after the feeding.
Question 22
A nurse is providing discharge teaching to a client who has a new prescription for home oxygen therapy via a nasal cannula. Which of the following instructions should the nurse include?
- “Wear synthetic clothing while using oxygen.”
- “Check the position of the cannula prongs in the nares regularly.”
- “Apply petroleum jelly to the nares if they become dry.”
- “Keep the oxygen tank at least 2 feet away from a heat source.”
Question 23
A nurse is caring for a client who is immobile. Which of the following interventions should the nurse include in the plan of care to prevent contractures?
- Perform range-of-motion exercises with the client.
- Place a pillow under the client’s knees while in bed.
- Massage the client’s bony prominences daily.
- Position the client with their hips in a neutral position.
Question 24
A nurse is reviewing the laboratory results for a client who has been receiving heparin. Which of the following results should the nurse report to the provider?
- aPTT 90 seconds
- Platelets 200,000/mm³
- Hgb 15 g/dL
- Hct 45%
Question 25
A nurse is assessing a client who has a hip fracture. Which of the following findings should the nurse expect?
- External rotation of the affected leg
- Internal rotation of the affected leg
- Lengthening of the affected leg
- Absence of pain in the affected hip
Question 26
A nurse is teaching a client who has a new prescription for a cane. Which of the following instructions should the nurse include?
- “Hold the cane on your weaker side.”
- “Move the cane and your stronger leg forward at the same time.”
- “Keep two points of support on the floor at all times.”
- “Position the top of the cane at the level of your waist.”
Question 27
A nurse is providing teaching to a client who has a new prescription for sublingual nitroglycerin. Which of the following instructions should the nurse include?
- “Swallow the tablet with a full glass of water.”
- “Place the tablet under your tongue and let it dissolve.”
- “Take the medication once every 12 hours.”
- “Crush the tablet before taking it.” RN Fundamentals 2023
Question 28
A nurse is caring for a client who has a prescription for a clear liquid diet. Which of the following items should the nurse offer the client?
- Gelatin
- Sherbet
- Milkshake
- Cream of chicken soup
Question 29
A nurse is preparing to perform a sterile dressing change for a client. Which of the following actions should the nurse take to maintain a sterile field?
- Drop sterile items onto the sterile field from a height of 6 inches.
- Reach across the sterile field to pick up an item.
- Place the cap of a sterile solution bottle facing down on a clean surface.
- Open the outermost flap of a sterile kit toward their body.
Question 30
A nurse is preparing to administer an intramuscular injection to an adult client. Which of the following actions should the nurse plan to take?
- Select a 25-gauge needle for the injection.
- Use a 5/8-inch needle for the injection.
- Inject the medication at a 90° angle.
- Massage the site after injecting the medication.
Question 31
A nurse is caring for a client who is in the terminal stage of a fatal disease. The client’s partner asks the nurse, “What can I do to help him?” Which of the following responses should the nurse make?
- “I will explain everything that is happening to him.”
- “Try to get him to eat as much as possible.”
- “Hold his hand and speak to him in a low voice.”
- “Limit your visits to 15 minutes at a time to let him rest.”
Question 32
A nurse is assessing a client’s readiness to learn about insulin self-administration. Which of the following findings should the nurse identify as a factor that can hinder the client’s ability to learn?
- The client is experiencing moderate pain.
- The client asks questions about the procedure.
- The client has a high school diploma.
- The client expresses interest in the information.
Question 33
A nurse is teaching a client about a clear liquid diet. Which of the following food choices should the nurse include in the teaching?
- Vanilla pudding
- Apple juice
- Orange juice with pulp
- Low-fat yogurt
Question 34
A nurse is providing teaching to a client who has a new prescription for an incentive spirometer. Which of the following instructions should the nurse include?
- “Hold your breath for 10 seconds after exhaling.”
- “Exhale into the spirometer as hard as possible.”
- “Place your lips tightly around the mouthpiece.”
- “Use the incentive spirometer every 4 hours while awake.”
Question 35
A nurse is providing teaching about food high in fiber to a client who has constipation. Which of the following foods should the nurse recommend?
- White beans
- Canned peaches
- White rice
- Processed cheese
Question 36
A nurse is reviewing a client’s medication administration record and notes a new prescription for a medication. The nurse should verify the client’s identity using which of the following methods?
- Ask the client’s roommate to state the client’s name.
- Compare the client’s name and date of birth on their identification band with the medication administration record.
- Check the client’s room number against the medication administration record. RN Fundamentals 2023
- Ask the client’s visitor to confirm the client’s identity.
Question 37
A nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following actions should the nurse take?
- Change the TPN IV tubing every 72 hr.
- Check the client’s capillary blood glucose every 6 hr.
- Speed up the infusion rate if the TPN bag is behind schedule.
- Maintain the TPN solution at room temperature for 48 hr.
Question 38
A nurse is preparing to administer a liquid medication to a client. Which of the following actions should the nurse take?
- Place the medication cup on a flat surface at eye level.
- Pour the medication so the label is facing away from the palm.
- Measure the medication at the top of the meniscus.
- Hold the medication cup in the air while pouring the medication.
Question 39
A nurse is caring for a client who has a prescription for a 24-hour urine collection. Which of the following actions should the nurse take?
- Discard the first voiding when beginning the collection. RN Fundamentals 2023
- Store the urine container in the client’s bathroom.
- Include the first voiding in the total collection.
- Restart the collection if the client voids into the toilet once.
Question 40
A nurse is caring for a client who is receiving morphine via a PCA pump. Which of the following findings is the nurse’s priority?
- Respiratory rate 7/min
- Urinary retention
- Constipation
- Nausea and vomiting
Question 43
A nurse is assessing a client who has a fluid volume deficit. Which of the following findings should the nurse expect?
- Postural hypotension
- Neck vein distension
- Bradycardia
- Crackles upon auscultation
Question 44
A nurse is preparing to document in a client’s electronic health record and is unable to remember their personal password. Which of the following actions should the nurse take?
- “I can give you the contact information for someone to assist you with recovering your password.”
- “I will give you my password so you can document the care you provided.”
- “I will document the care you provided for you.”
- “Ask another nurse if they can let you use their password.”
Question 45
A nurse is caring for a client who has a durable power of attorney. The nurse should identify that this document is enforceable when which of the following occurs?
- The client is unable to express their wishes.
- The client is admitted to a healthcare facility.
- The client has a terminal illness.
- The client’s family disagrees with the plan of care.
Question 46
A nurse is preparing to administer amoxicillin 80 mg/kg/day to be divided into 4 equal doses to a client who weighs 20 kg. How many mg 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.)
- 400
Question 47
A nurse is providing teaching to a client who has a new prescription for two different ophthalmic medications. Which of the following instructions should the nurse include?
- Wait 5 min between the administration of each medication.
- Rub the eyes after administering each medication.
- Close the eyes tightly for 30 seconds after administering the drops.
- Apply the drops directly to the center of the cornea.
Question 48
A nurse is witnessing a client sign an informed consent form for a surgical procedure. The nurse should identify that their signature witnesses which of the following? (Select all that apply.)
- The client was not coerced.
- The client signed in the nurse’s presence.
- The client has legal authority to do so.
- The client understands the risks of the procedure.
- The client has been informed of alternative treatments.
Question 49
A nurse is preparing to perform a physical assessment for a client who has reported abdominal pain. Which of the following actions should the nurse take first?
- Auscultate bowel sounds.
- Inspect the abdomen.
- Palpate the abdomen.
- Percuss the abdomen.
Question 50
A nurse is providing teaching about medication safety to an older adult client. Which of the following statements by the client indicates an understanding of the teaching?
- “My medications could interact with foods that I eat.”
- “I should stop taking my medications once I feel better.”
- “I will store my medications in the kitchen cabinet above the stove.”
- “I should use the same measuring spoon for all my liquid medications.”
Question 51
A nurse is planning to move a client from the bed to a chair using the logrolling technique. Which of the following statements should the nurse make?
- “Logrolling will keep your spine in alignment.”
- “You should reach for the chair once we start to move.”
- “I will pull on your arms to help you sit up.”
- “You will need to twist your waist as we move.”
Question 52
A nurse is caring for a client who is scheduled for surgery and states, “I have decided not to have the procedure.” Which of the following actions should the nurse take? RN Fundamentals 2023
- Let the client know that their surgeon will be notified of their decision.
- Tell the client that they have already signed the consent form.
- Explain the benefits of the surgery to the client.
- Ask the client’s family to convince them to have the surgery.
Question 53
A nurse is teaching a newly licensed nurse about the prevention of catheter-associated urinary tract infections (CAUTI). Which of the following instructions should the nurse include?
- “Keep the collection bag below bladder level.”
- “Empty the collection bag once every 24 hours.”
- “Use clean technique when performing catheter care.”
- “Irrigate the catheter with sterile saline daily.”
Question 54
A nurse is caring for a client who is 6 hr postoperative following abdominal surgery and is having difficulty voiding. Which of the following actions should the nurse take?
- Provide the client a bedpan while lying supine.
- Insert an indwelling urinary catheter and connect it to gravity drainage.
- Allow the client to hear running water while attempting to void.
- Encourage fluid intake up to 1,000 mL daily.
Question 55
A nurse is teaching a client who can only bear weight on one leg how to ambulate using crutches. Which of the following crutch gaits should the nurse plan to instruct the client to use?
- Three-point gait
- Swing-through gait
- Four-point alternating gait
- Two-point alternating gait
Question 56
A nurse is preparing to collect a sputum specimen from a client. Which of the following actions should the nurse take?
- Place the sputum specimen in a clean container.
- Obtain the sputum specimen after the client uses mouthwash.
- Collect the sputum specimen in the morning.
- Use sterile gloves to obtain the sputum specimen.
Question 57
A home health nurse is performing a fall risk assessment for an older adult client. Which of the following findings should the nurse identify as a potential fall risk in the home?
- The client has electrical wires secured to baseboards.
- The client takes an antihypertensive medication.
- The client wears rubber-sole shoes.
- The client’s visual acuity is 20/40.
Question 58
A nurse is preparing to document in the client’s medical record. The nurse should identify that which of the following abbreviations are specified by The Joint Commission for placement on a facility’s Do Not Use list? (Select all that apply.)
- I&O
- U
- IU
- PRN
- q.d.
Question 59
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.
- Administer 240 mL (8 oz) of oral contrast before the procedure.
- Monitor the client for pain in the suprapubic region.
- Assist the client with a bowel cleansing.
Question 60
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.”
- “Each element has a range from one to five points.”
- “The higher the score, the higher the pressure injury risk.”
- “The scale measures six elements.”
Question 61
A nurse enters a client’s room and finds the client on the floor having a seizure. Which of the following actions should the nurse take?
- Lift the client to the bed with assistance.
- Turn the client onto their back.
- Clear the nearby area of furniture.
- Place a tongue depressor in the client’s mouth. RN Fundamentals 2023
Question 62
A nurse is providing discharge teaching to the partner of a client who has a linear incision site following an open cholecystectomy. Which of the following wound care instructions should the nurse include?
- Clean from the incision to the surrounding skin.
- Use sterile gloves when removing the old dressing.
- Apply tincture of benzoin prior to removing the dressing.
- Change the dressing four times per day.
Question 63
A nurse says to their nurse manager that, “I’m the only one on my team who is working hard.” Which of the following responses should the nurse manager make?
- “I will reprimand your team members.”
- “You must feel frustrated.”
- “You should be working harder.”
- “Why do you feel upset about this?”
Question 64
A nurse is caring for a client who has a traumatic brain injury and needs to relearn how to use eating utensils. The nurse should refer the client to which of the following members of the interprofessional team?
- Speech-language pathologist
- Social worker
- Occupational therapist
- Physical therapist
Question 65
A nurse is ambulating a client who is unsteady. The client begins to fall. Which of the following actions should the nurse take?
- Move quickly to a position in front of the client.
- Place their arms around the client to prevent the fall.
- Remain upright as the client falls toward them.
- Allow the client to slide down their outstretched leg.
Question 66
A nurse is assessing a client whose partner is receiving hospice care and is dying. The client states, “I should start planning the trip that we want to take.” Which of the following ego-defense mechanisms is the client expressing?
- Denial
- Displacement
- Regression
- Dissociation
Question 67
A nurse is providing care for a client who is to undergo a total laryngectomy. Which of the following interventions is the nurse’s priority?
- Schedule a support session for the client.
- Explain the techniques of esophageal speech.
- Review the use of an artificial larynx with the client.
- Determine the client’s reading ability.
Question 68
A nurse is reviewing the medical record of a client who has a paralytic ileus. Drag words from the choices below to fill in each blank in the following sentence. The findings in the client’s medical record indicate Target 1 and Target 2.
- Conditions: dehydration, pneumothorax, infection, hyperglycemia
- Hyperglycemia
- Infection
