Fundamentals Practice Exam Question & Answers 2024, Exams of Nursing

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& Answers 2024

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 Answers ✅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 Answers ✅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.

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B. 83 gtt/min. C. 125 gtt/min. D. 250 gtt/min. - Correct Answers ✅C. 125 gtt/min Which assessment data provides the most accurate determination of proper placement of a nasogastric tube? - Correct Answers ✅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 Answers ✅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

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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 Answers ✅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 Answers ✅C. After clearing the tube with 30 ml of air, check the pH of fluid withdrawn from the tube

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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 Answers ✅D. Is disoriented to place and time A client with chronic kidney disease (CKD) selects a scrambled egg for his breakfast. What action should the nurse take? - Correct Answers ✅A. Commend the client for selecting a high biologic value protein When assisting an 82-year-old client to ambulate, it is important for the nurse to realize that the center of gravity for an elderly person is the A. Arms. B. Upper torso. C. Head. D. Feet. - Correct Answers ✅B. Upper torso In developing a plan of care for a client with dementia, the nurse should remember that confusion in the elderly A. is to be expected, and progresses with age. B. often follows relocation to new surroundings. C. is a result of irreversible brain pathology. D. can be prevented with adequate sleep. - Correct Answers ✅B. Often follows relocation to new surroundings

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A postoperative client will need to perform daily dressing changes after discharge. Which outcome statement best demonstrates the client's readiness to manage his wound care after discharge? The client - Correct Answers ✅C. demonstrates the wound care procedure correctly A client who is 5'5 tall and weighs 200 pounds is scheduled for surgery the next day. What question is most important for the nurse to include during the preoperative assessment? - Correct Answers ✅B. "What vitamin and mineral supplements do you take?" During the initial assessment, a male client denies dysuria but reports that his urine appears dark amber. Which intervention should the nurse implement? - Correct Answers ✅D. Encourage additional oral intake of juices and water Which intervention is most important for the nurse to implement for a male client who is experiencing urinary retention? A. Apply a condom catheter. B. Apply a skin protectant. C. Encourage increased fluid intake. D. Assess for bladder distention. - Correct Answers ✅D. Assess for bladder distention

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A client with acute hemorrhagic anemia is to receive four units of packed RBCs (red blood cells) as rapidly as possible. Which intervention is most important for the nurse to implement? - Correct Answers ✅D. Ensure the accuracy of the blood type match A male client being discharged with a prescription for the bronchodilator theophylline tells the nurse that he understands he is to take three doses of the medication each day. Since, at the time of discharge, timed-release capsules are not available, which dosing schedule should the nurse advise the client to follow? A. 9 a.m., 1 p.m., and 5 p.m. B. 8 a.m., 4 p.m., and midnight. C. Before breakfast, before lunch and before dinner. D. With breakfast, with lunch, and with dinner. - Correct Answers ✅B. 8 a.m., 4 p.m., and midnight A client is to receive 10 mEq of KCl diluted in 250 ml of normal saline over 4 hours. At what rate should the nurse set the client's IV infusion pump? - Correct Answers ✅B. 63 ml/hr When evaluating a client's plan of care, the nurse determines that a desired outcome was not achieved. Which action should he nurse implement first? - Correct Answers ✅B. Note which actions were not implemented

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Which snack food is best for the nurse to provide a client with myasthenia gravis who is at risk for altered nutritional status? - Correct Answers ✅A. Chocolate pudding The nurse is instructing a client with high cholesterol about diet and life style modification. What comment from the client indicates that the teaching has been effective? A. If I exercise at least two times weekly for one hour, I will lower my cholesterol. B. I need to avoid eating proteins, including red meat. C. I will limit my intake of beef to 4 ounces per week. D. My blood level of low density lipoproteins needs to increase. - Correct Answers ✅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.

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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 Answers ✅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 Answers ✅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 Answers ✅D. 180

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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 Answers ✅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 Answers ✅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 Answers ✅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

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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 Answers ✅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 Answers ✅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 Answers ✅C. "It is OK if you don't want to talk about your surgery. I will be available when you are ready.:

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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 Answers ✅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 Answers ✅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?

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A. Prone. B. Fowler's. C. Sims'. D. Supine. - Correct Answers ✅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 Answers ✅Keep gloved hands above the elbows The nurse is teaching a client with numerous allergies how to avoid allergens. Which instruction should be included in this teaching plan? A. Avoid any types of sprays, powders, and perfumes. B. Wearing a mask while cleaning will not help to avoid allergens. C. Purchase any type of clothing, but be sure it is washed before wearing it. D. Pollen count is related to hay fever, not to allergens. - Correct Answers ✅A. Avoid any types of sprays, powders, and perfumes

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A 73-year-old female client had a hemiarthroplasty of the left hip yesterday due to a fracture resulting from a fall. In reviewing hip precautions with the client, which instruction should the nurse include in this client's teaching plan? - Correct Answers ✅B. "Place a pillow between your knees while lying in bed to prevent hip dislocation." The nurse is performing nasotracheal suctioning. After suctioning the client's trachea for fifteen seconds, large amounts of thick yellow secretions return. What action should the nurse implement next? A. Encourage the client to cough to help loosen secretions. B. Advise the client to increase the intake of oral fluids. C. Rotate the suction catheter to obtain any remaining secretions. D. Re-oxygenate the client before attempting to suction again. - Correct Answers ✅D. Re-oxygenate the client before attempting to suction again A client's infusion of normal saline infiltrated earlier today, and approximately 500 ml of saline infused into the subcutaneous tissue. The client is now complaining of excruciating arm pain and demanding "stronger pain medications." What initial action is most important for the nurse to take? A. Ask about any past history of drug abuse or addiction. B. Measure the pulse volume and capillary refill distal to the infiltration. C. Compress the infiltrated tissue to measure the degree of edema.

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D. Evaluate the extent of ecchymosis over the forearm area. - Correct Answers ✅B. Measure the pulse volume and capillary refill distal to the infiltration The nurse assigns a UAP to obtain vital signs from a very anxious client. What instructions should the nurse give the UAP? A. Remain calm with the client and record abnormal results in the chart. B. Notify the medication nurse immediately if the pulse or blood pressure is low. C. Report the results of the vital signs to the nurse. D. Reassure the client that the vital signs are normal. - Correct Answers ✅C. Report the results of the vital signs to the nurse Twenty minutes after beginning a heat application, the client states that the heating pad no longer feels warm enough. What is the best response by the nurse? A. That means you have derived the maximum benefit, and the heat can be removed. B. Your blood vessels are becoming dilated and removing the heat from the site. C. We will increase the temperature 5 degrees when the pad no longer feels warm.

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D. The body's receptors adapt over time as they are exposed to heat. - Correct Answers ✅D. "The body's receptors adapt over time as they are exposed to heat." When assessing a client with wrist restraints, the nurse observes that the fingers on the right hand are blue. What action should the nurse implement first. - Correct Answers ✅A. Loosen the right wrist restraint An elderly client who requires frequent monitoring fell and fractured a hip. Which nurse is at greatest risk for a malpractice judgment? A. A nurse who worked the 7 to 3 shift at the hospital and wrote poor nursing notes. B. The nurse assigned to care for the client who was at lunch at the time of the fall. C. The nurse who transferred the client to the chair when the fall occurred. D. The charge nurse who completed rounds 30 minutes before the fall occurred. - Correct Answers ✅C. The nurse who transferred the client to the chair when the fall occured The nurse observes an unlicensed assistive personnel (UAP) taking a client's blood pressure with a cuff that is too small, but the blood pressure reading obtained is within the client's usual range. What action is most important for the nurse to implement?

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A. Tell the UAP to use a larger cuff at the next scheduled assessment. B. Reassess the client's blood pressure using a larger cuff. C. Have the unit educator review this procedure with the UAPs. D. Teach the UAP the correct technique for assessing blood pressure. - Correct Answers ✅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 Answers ✅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 Answers ✅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.

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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 Answers ✅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 Answers ✅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 Answers ✅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.

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C. Administer the medications as prescribed. D. Crush the tablets and dissolve in sterile water. - Correct Answers ✅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 Answers ✅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 Answers ✅A. Acknowledge that she is supporting the arm correctly

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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 Answers ✅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 Answers ✅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 Answers ✅B. Blood tranfusion are forbidden

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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 Answers ✅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 Answers ✅A. Give an around-the-clock schedule for administration of analgesics

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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 Answers ✅A. Assist the ambulating client back to the bed A female client asks the nurse to find someone who can translate into her native language her concerns about a treatment. Which action should the nurse take? A. Explain that anyone who speaks her language can answer her questions. B. Provide a translator only in an emergency situation. C. Ask a family member or friend of the client to translate. D. Request and document the name of the certified translator. - Correct Answers ✅D. Request and document the name of the certified translator An African-American grandmother tells the nurse that her 4-year-old grandson is suffering with "miseries." Based on this statement, which focused assessment should the nurse conduct? A. Inquire about the source and type of pain. B. Examine the nose for congestion and discharge. C. Take vital signs for temperature elevation. D. Explore the abdominal area for distension. - Correct Answers ✅A. Inquire about the source and type of pain

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The nurse notices that the mother a 9-year-old Vietnamese child always looks at the floor when she talks to the nurse. What action should the nurse take? A. Talk directly to the child instead of the mother. B. Continue asking the mother questions about the child. C. Ask another nurse to interview the mother now. D. Tell the mother politely to look at you when answering. - Correct Answers ✅B. Continue asking the mother questions about the child The nurse notices that the Hispanic parents of a toddler who returns from surgery offer the child only the broth that comes on the clear liquid tray. Other liquids, including gelatin, popsicles, and juices, remain untouched. What explanation is most appropriate for this behavior? A. The belief is held that the "evil eye" enters the child if anything cold is ingested. B. After surgery the child probably has refused all foods except broth. C. Eating broth strengthens the child's innate energy called "chi." D. Hot remedies restore balance after surgery, which is considered a "cold" condition. - Correct Answers ✅D. "Hot" remedies restore balance after surgery, which is considered a "Cold" condition Which nutritional assessment data should the nurse collect to best reflect total muscle mass in an adolescent?

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A. Height in inches or centimeters. B. Weight in kilograms or pounds. C. Triceps skin fold thickness. D. Upper arm circumference. - Correct Answers ✅D. Upper arm circumference A client is receiving a cephalosporin antibiotic IV and complains of pain and irritation at the infusion site. The nurse observes erythema, swelling, and a red streak along the vessel above the IV access site. Which action should the nurse take at this time? A. Administer the medication more rapidly using the same IV site. B. Initiate an alternate site for the IV infusion of the medication. C. Notify the healthcare provider before administering the next dose. D. Give the client a PRN dose of aspirin while the medication infuses. - Correct Answers ✅B. Initiate an alternate site for the IV infusion of the medication On admission, a client presents a signed living will that includes a Do Not Resuscitate (DNR) prescription. When the client stops breathing, the nurse performs cardiopulmonary resuscitation (CPR) and successfully revives the client. What legal issues could be brought against the nurse? A) Assault.

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B) Battery. C) Malpractice. D) False imprisonment. - Correct Answers ✅B. Battery A resident in a skilled nursing facility for short-term rehabilitation after a hip replacement tells the nurse "I don't want any more blood taken for those useless tests." Which narrative documentation should the nurse enter in the client's medical record? - Correct Answers ✅C. Healthcare provider notified of client's refusal to have blood specimens collected for testing At the beginning of the shift, the nurse assesses a client who is admitted from the post-anesthesia care unit (PACU). When should the nurse document the client's findings? 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 Answers ✅D. Immediately after the assessments are completed

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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 Answers ✅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 Answers ✅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 Answers ✅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 Answers ✅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