Fundamentals Practice Exam 83 Questions with Verified Answers,100% CORRECT, Exams of Nursing

Download Fundamentals Practice Exam 83 Questions with Verified Answers,100% CORRECT and more Exams Nursing in PDF only on Docsity! Fundamentals Practice Exam 83 Questions with Verified Answers The nurse observes that a male client has removed the covering from an ice pack applied to his knee. What action should the nurse take first? A. Observe the appearance of the skin under the ice pack. B. Instruct the client regarding the need for the covering. C. Reapply the covering after filling with fresh ice. D. Ask the client how long the ice was applied to the skin. - CORRECT ANSWER A The nurse mixes 50 mg of Nipride in 250 ml of D5W and plans to administer the solution at a rate of 5 mcg/kg/min to a client weighing 182 pounds. Using a drip factor of 60 gtt/ml, how many drops per minute should the client receive? A. 31 gtt/min. B. 62 gtt/min. C. 93 gtt/min. D. 124 gtt/min. - CORRECT ANSWER C. 93 gtt/min The healthcare provider prescribes 1,000 ml of Ringer's Lactate with 30 Units of Pitocin to run in over 4 hours for a client who has just delivered a 10 pound infant by cesarean section. The tubing has been changed to a 20 gtt/ml administration set. The nurse plans to set the flow rate at how many gtt/min? A. 42 gtt/min. B. 83 gtt/min. C. 125 gtt/min. D. 250 gtt/min. - CORRECT ANSWER C. 125 gtt/min Which assessment data provides the most accurate determination of proper placement of a nasogastric tube? - CORRECT ANSWER C. Examining a chest x-ray obtained after the tubing was inserted Three days following surgery, a male client observes his colostomy for the first time. He becomes quite upset and tells the nurse that it is much bigger than he expected. What is the best response by the nurse? A. Reassure the client that he will become accustomed to the stoma appearance in time. B. Instruct the client that the stoma will become smaller when the initial swelling diminishes. C. Offer to contact a member of the local ostomy support group to help him with his concerns. D. Encourage the client to handle the stoma equipment to gain confidence with the procedure. - CORRECT ANSWER B. Instruct the client that the stoma will become smaller when the initial swelling diminishes A female client with a nasogastric tube attached to low suction states that she is nauseated. The nurse assesses that there has been no drainage through the nasogastric tube in the last two hours. What action should the nurse take first? A. Irrigate the nasogastric tube with sterile normal saline. B. Reposition the client on her side. C. Advance the nasogastric tube an additional five centimeters. D. Administer an intravenous antiemetic prescribed for PRN use. - CORRECT ANSWER B. Reposition the client on her side A hospitalized male client is receiving nasogastric tube feedings via a small-bore tube and a continuous pump infusion. He reports that he had a bad bout of severe coughing a few minutes ago, but feels fine now. What action is best for the nurse to take? A. Record the coughing incident. No further action is required at this time. B. Stop the feeding, explain to the family why it is being stopped, and notify the healthcare provider. C. After clearing the tube with 30 ml of air, check the pH of fluid withdrawn from the tube. D. Inject 30 ml of air into the tube while auscultating the epigastrium for gurgling. - CORRECT ANSWER C. After clearing the tube with 30 ml of air, check the pH of fluid withdrawn from the tube A male client tells the nurse that he does not know where he is or what year it is. What data should the nurse document that is most accurate? - CORRECT ANSWER D. Is disoriented to place and time D. My blood level of low density lipoproteins needs to increase. - CORRECT ANSWER C. "I will limit my intake of beef to 4 ounces per week" An obese male client discusses with the nurse his plans to begin a long-term weight loss regimen. In addition to dietary changes, he plans to begin an intensive aerobic exercise program 3 to 4 times a week and to take stress management classes. After praising the client for his decision, which instruction is most important for the nurse to provide? A. Be sure to have a complete physical examination before beginning your planned exercise program. B. Be careful that the exercise program doesn't simply add to your stress level, making you want to eat more. C. Increased exercise helps to reduce stress, so you may not need to spend money on a stress management class. D. Make sure to monitor your weight loss regularly to provide a sense of accomplishment and motivation. - CORRECT ANSWER A. "Be sure to have a complete physical examination before beginning your planned exercise program." The nurse is teaching a client proper use of an inhaler. When should the client administer the inhaler-delivered medication to demonstrate correct use of the inhaler? A. Immediately after exhalation. B. During the inhalation. C. At the end of three inhalations. D. Immediately after inhalation. - CORRECT ANSWER B. During inhalation An IV infusion terbutaline sulfate 5 mg in 500 ml of D5W, is infusing at a rate of 30 mcg/min prescribed for a client in premature labor. How many ml/hr should the nurse set the infusion pump? A. 30 B. 60 C. 120 D. 180 - CORRECT ANSWER D. 180 The healthcare provider prescribes the diuretic metolazone (Zaroxolyn) 7.5 mg PO. Zaroxolyn is available in 5 mg tablets. How much should the nurse plan to administer? A. ½ tablet. B. 1 tablet. C. 1½ tablets. D. 2 tablets. - CORRECT ANSWER C. 1 1/2 tablets The healthcare provider prescribes furosemide (Lasix) 15mg IV stat. On hand is Lasix 20 mg/2ml. Haw many ml shoudl the nurse administer - CORRECT ANSWER B. 1.5 ml Heparin 20,000 units in 500 ml D5W at 50 ml/hour has been infusing for 5½ hours. How much heparin has the client received? A. 11,000 units. B. 13,000 units. C. 15,000 units. D. 17,000 units. - CORRECT ANSWER A. 11,000 units The nurse is caring for a client who is receiving 24-hour total parenteral nutrition (TPN) via a central line at 54 ml/hr. When initially assessing the client, the nurse notes that the TPN solution has run out and the next TPN solution is not available. What immediate action should the nurse take? A. Infuse normal saline at a keep vein open rate. B. Discontinue the IV and flush the port with heparin. C. Infuse 10 percent dextrose and water at 54 ml/hr. D. Obtain a stat blood glucose level and notify the healthcare provider. - CORRECT ANSWER C. Infuse 10% dextrose and water at 54 ml.hr Examination of a client complaining of itching on his right arm reveals a rash made up of multiple flat areas of redness ranging from pinpoint to 0.5 cm in diameter. How should the nurse record this finding? A. Multiple vesicular areas surrounded by redness, ranging in size from 1 mm to 0.5 cm. B. Localized red rash comprised of flat areas, pinpoint to 0.5 cm in diameter. C. Several areas of red, papular lesions from pinpoint to 0.5 cm in size. D. Localized petechial areas, ranging in size from pinpoint to 0.5 cm in diameter. - CORRECT ANSWER B. Localized red rash comprised of flat areas, pinpoint to 0.5 cm in diameter At the time of the first dressing change, the client refuses to look at her mastectomy incision. What would be an appropriate response to this client's silence - CORRECT ANSWER C. "It is OK if you don't want to talk about your surgery. I will be available when you are ready.: The nurse is evaluating client learning about a low-sodium diet. Selection of which meal would indicate to the nurse that this client understands the dietary restrictions? A. Tossed salad, low-sodium dressing, bacon and tomato sandwich. B. New England clam chowder, no-salt crackers, fresh fruit salad. C. Skim milk, turkey salad, roll, and vanilla ice cream. D. Macaroni and cheese, diet Coke, a slice of cherry pie. - CORRECT ANSWER C. Skim milk, turkey salad, roll and vanilla ice cream The nurse prepares a 1,000 ml IV of 5% dextrose and water to be infused over 8 hours. The infusion set delivers 10 drops per milliliter. The nurse should regulate the IV to administer approximately how many drops per minute? A. 80 B. 8 C. 21 D. 25 - CORRECT ANSWER C. 21 An elderly male client who is unresponsive following a cerebral vascular accident (CVA) is receiving bolus enteral feedings though a gastrostomy tube. What is the best client position for administration of the bolus tube feedings? A. Prone. B. Fowler's. C. Sims'. D. Supine. - CORRECT ANSWER B. Fowler's Which action is most important for the nurse to implement when donning sterile gloves? A. Maintain thumb at a ninety degree angle. B. Hold hands with fingers down while gloving. C. Keep gloved hands above the elbows. D. Put the glove on the dominant hand first. - CORRECT ANSWER Keep gloved hands above the elbows C. Have the unit educator review this procedure with the UAPs. D. Teach the UAP the correct technique for assessing blood pressure. - CORRECT ANSWER B. Reassess the client's blood pressure using a larger cuff An elderly client with a fractured left hip is on strict bedrest. Which nursing measure is essential to the client's nursing care? - CORRECT ANSWER D. Gently lift the client when moving into a desired position The UAPs working on a chronic neuro unit ask the nurse to help them determine the safest way to transfer an elderly client with left-sided weakness from the bed to the chair. What method describes the correct transfer procedure for this client - CORRECT ANSWER D. Move the chair parallel to the right side of the bed, and stand the client on the right foot An elderly resident of a long-term care facility is no longer able to perform self- care and is becoming progressively weaker. The resident previously requested that no resuscitative efforts be performed, and the family requests hospice care. What action should the nurse implement first? A. Reaffirm the client's desire for no resuscitative efforts. B. Transfer the client to a hospice inpatient facility. C. Prepare the family for the client's impending death. D. Notify the healthcare provider of the family's request. - CORRECT ANSWER D. Notify the healthcare provider of the family's request After completing an assessment and determining that a client has a problem, which action should the nurse perform next? A. Determine the etiology of the problem. B. Prioritize nursing care interventions. C. Plan appropriate interventions. D. Collaborate with the client to set goals. - CORRECT ANSWER A. Determine the etiology of the problem What is the most important reason for starting IV infusions in the upper extremities rather than the lower extremities of adults - CORRECT ANSWER B. A decreased flow rate could result in the formation a thrombosis The nurse is administering medications through a nasogastric tube (NGT) which is connected to suction. After ensuring correct tube placement, what action should the nurse take next? A. Clamp the tube for 20 minutes. B. Flush the tube with water. C. Administer the medications as prescribed. D. Crush the tablets and dissolve in sterile water. - CORRECT ANSWER B. Flush the tube with water A client is in the radiology department at 0900 when the prescription levofloxacin (Levaquin) 500 mg IV q24h is scheduled to be administered. The client returns to the unit at 1300. What is the best intervention for the nurse to implement? A. Contact the healthcare provider and complete a medication variance form. B. Administer the Levaquin at 1300 and resume the 0900 schedule in the morning. C. Notify the charge nurse and complete an incident report to explain the missed dose. D. Give the missed dose at 1300 and change the schedule to administer daily at 1300. - CORRECT ANSWER D. Give the missed dose at 1300 and change the schedule to administer daily at 1300 While instructing a male client's wife in the performance of passive range-of- motion exercises to his contracted shoulder, the nurse observes that she is holding his arm above and below the elbow. What nursing action should the nurse implement? - CORRECT ANSWER A. Acknowledge that she is supporting the arm correctly An adult male client with a history of hypertension tells the nurse that he is tired of taking antihypertensive meds and will be trying meditation instead. What should the nurse say? - CORRECT ANSWER A. "It is important that you continue your medication while learning to meditate." The nurse is assessing the nutritional status of several clients. Which client has the greatest nutritional need for additional intake of protein? A. A college-age track runner with a sprained ankle. B. A lactating woman nursing her 3-day-old infant. C. A school-aged child with Type 2 diabetes. D. An elderly man being treated for a peptic ulcer. - CORRECT ANSWER B. A lactating woman nursing her 3-day old infant A client who is a Jehovah's Witness is admitted to the nursing unit. Which concern should the nurse have for planning care in terms of the client's beliefs? A. Autopsy of the body is prohibited. B. Blood transfusions are forbidden. C. Alcohol use in any form is not allowed. D. A vegetarian diet must be followed. - CORRECT ANSWER B. Blood tranfusion are forbidden When conducting an admission assessment, the nurse should ask the client about the use of complimentary healing practices. Which statement is accurate regarding the use of these practices? A. Complimentary healing practices interfere with the efficacy of the medical model of treatment. B. Conventional medications are likely to interact with folk remedies and cause adverse effects. C. Many complimentary healing practices can be used in conjunction with conventional practices. D. Conventional medical practices will ultimately replace the use of complimentary healing practices. - CORRECT ANSWER C. Many complimentary healing practices can be used in conjuction with conventional practices A client who is in hospice care complains of increasing amounts of pain. The healthcare provider prescribes an analgesic every four hours as needed. Which action should the nurse implement? A. Give an around-the-clock schedule for administration of analgesics. B. Administer analgesic medication as needed when the pain is severe. C. Provide medication to keep the client sedated and unaware of stimuli. D. Offer a medication-free period so that the client can do daily activities. - CORRECT ANSWER A. Give an around-the-clock schedule for administration of analgesics A client with pneumonia has a decrease in oxygen saturation from 94-88% while ambulating. Base on these findings, which intervention should the nurse implement. - CORRECT ANSWER A. Assist the ambulating client back to the bed A) At the beginning, middle, and end of the shift. B) After client priorities are identified for the development of the nursing care plan. C) At the end of the shift so full attention can be given to the client's needs. D) Immediately after the assessments are completed - CORRECT ANSWER D. Immediately after the assessments are completed A Sub-Saharan African widowed immigrant woman lives with her deceases husband's brother and his family, which includes the brother-in-law's children and the widow's adult children, Each family member speaks fluent English. Surgery was recommended for the client. What is the best plan to obtain consent for surgery for this client? - CORRECT ANSWER D. Tell the surgeon that the brother- in-law will decide after explanation of the proposed surgery is provided to him and the widow Which response by a client with a nursing diagnosis of "Spiritual distress," indicates to the nurse that a desired outcome measure has been met? - CORRECT ANSWER C. Accepts that punishment from God is not related to illness During shift change report, the nurse receives report that a client has abnormal heart sounds. Which placement of the stethoscope should the nurse use to hear the client's heart sounds? - CORRECT ANSWER B. Use the stethoscope bell over the valvular areas of the anterior chest A nurse is preparing to give meds through a nasogastric feeding tube. Which nursing action should prevent complications during administration? - CORRECT ANSWER A. Mix each med individually During the admission interview, which technique is most efficient for the nurse to use when obtaining information about signs and symptoms of a client's primary health problem? - CORRECT ANSWER C. Closed-ended questions The nurse witnesses the signature of a client who has signed an informed consent. Which statement best explains this nursing responsibility? A. The client voluntarily signed the form. B. The client fully understands the procedure. C. The client agrees with the procedure to be done. D. The client authorizes continued treatment. - CORRECT ANSWER A. The client voluntarily signed the form An older client who is a resident in a long term care facility has been bedridden for a week. Which finding should the nurse identify as a client risk factor for pressure ulcers? - CORRECT ANSWER D. Rashes in the axillary, groin, and skin fold regions During a visit to the outpatient clinic, the nurse assesses a client with severe osteoarthritis using a goniometer. Which finding should the nurse expect to measure? A. Adequate venous blood flow to the lower extremities. B. Estimated amount of body fat by an underarm skinfold. C. Degree of flexion and extension of the client's knee joint. D. Change in the circumference of the joint in centimeters. - CORRECT ANSWER C. Degree of flexion and extension of the client's knee joint The nurse is completing a mental assessment for a client who is demonstrating slow thought processes, personality changes, and emotional lability. Which area of the brain controls these neuro-cognitive functions? A. Thalamus. B. Hypothalamus. C. Frontal lobe. D. Parietal lobe. - CORRECT ANSWER C. Frontal lobe An unlicensed assistive personnel (UAP) places a client in a left lateral position prior to administering a soap suds enema. Which instruction should the nurse provide the UAP? A. Position the client on the right side of the bed in reverse Trendelenburg. B. Fill the enema container with 1000 ml of warm water and 5 ml of castile soap. C. Reposition in a Sim's position with the client's weight on the anterior ilium. D. Raise the side rails on both sides of the bed and elevate the bed to waist level. - CORRECT ANSWER C. Reposition in a Sim's position with the client's weight on the anterior ilium A young mother of three children complains of increased anxiety during her annual physical exam. What information should the nurse obtain first? - CORRECT ANSWER B. Nutritional History A client who has been NPO for 3 days is receiving an infusion of D5W 0.45 - CORRECT ANSWER C. Document in the medical record that these normal findings are expected outcomes Secobarbital (Seconal) 150 mg is prescribed at bedtime for a male client who is scheduled for surgery in the morning. The scored tablets are labeled 0.1 gram/tablet. How many tablets should the nurse administer? (Enter the numerical value only. If rounding is required, round to the nearest tenth) - CORRECT ANSWER 1.5 What action should the nurse implement when accessing an implanted infusion port for a client who receives long term IV meds - CORRECT ANSWER B. Insert a Huber-point needle into the port During the daily nursing assessment, a client begins to cry and states that the majority of family and friends have stopped calling and visiting. What action should the nurse take? - CORRECT ANSWER A. Listen and show interest as the client expresses these feeling The nurse plans to obtain health assessment information from a primary source. Which option is a primary source for the completion of the health assessment? - CORRECT ANSWER A. Client The nurse is using a genogram while conducting a client's health assessment and past medical history. What information should the genogram provide? - CORRECT ANSWER A. Genetic and familial health disorders