Fundamentals practice test A

A nurse is performing a skin assessment for a client who expresses concern about skin cancer. which of the following findings should the nurse identify as a potential indication of a skin malignancy? 1) A mole with an asymmetrical appearance 2) A lesion with uniform pigmentation 3) New appearance of petechiae 4) The presence of a papule

A mole with an asymmetrical appearance

A nurse is preparing to administer enoxaparin SQ to a client. Which of the following actions should the nurse take? 1) Administer the medication with the needle at a 45° angle. 2) Administer the medication into the client's nondominant arm. 3) Pull the client's skin laterally or downward prior to administration. 4) Massage the injection site after administration.

Administer the medication with the needle at a 45° angle.

A nurse is educating a client who has a terminal illness about declining resuscitation in a living will. The client asks, "what would happen if I arrived at the ED and I had difficulty breathing?" Which of the following responses should the nurse make? 1) "We would consult the person appointed by your health care proxy to make decisions. 2) "We would give you oxygen through a tube in your nose." 3) "You would be unable to change your previous wishes about your care." 4) "We would insert a breathing tube while we evaluate your condition."

"We would give you oxygen through a tube in your nose."

A nurse is responding to a call light and finds a client lying on the bathroom floor. Which of the following actions should the nurse take first? 1) Check the client for injuries. 2) Move hazardous objects away from the client. 3) Notify the provider. 4) Ask the client to describe how she felt prior to the fall.

Check the client for injuries.

A nurse is planning care for a client who has had a stroke, resulting in aphasia and dysphagia. Which of the following tasks should the nurse assign to an AP? select all that apply 1) Assist the client with a partial bed bath. 2) Measure the client's BP after the nurse administers an antihypertensive medication. 3) Test the client's swallowing ability by providing thickened liquids. 4) Use a communication board to ask what the client wants for lunch. 5) Irrigate the client's indwelling urinary catheter.

1) Assist the client with a partial bed bath. 2) Measure the client's BP after the nurse administers an antihypertensive medication. 4) Use a communication board to ask what the client wants for lunch.

A nurse is assessing an older adult client's risk for falls. Which of the following assessments should the nurse use to identify the client's safety needs? select all that apply 1) Lacrimal apparatus 2) Pupil clarity 3)Appearance of bulbar conjunctivae 4) Visual fields 5) Visual acuity

2) Pupil clarity 4) Visual fields 5) Visual acuity

A nurse in a long term care facility is caring for a client who dies during the nurse's shift. Identify the sequence in which the nurse should perform the following steps. 1) place a name tag on the body 2) wash the client's body 3) obtain the pronouncement of death from the provider 4) remove tubes and indwelling lines 5) ask the client's family members if they would like to view the body

3, 4, 2, 5, 1

A nurse is evaluating a client's use of a cane. Which of the following actins should the nurse identify as an indication of correct use? 1) The top of the cane is parallel to the client's waist. 2) When walking, the client moves the cane 46 cm (18 in) forward. 3) The client holds the cane on the stronger side of her body. 4) The client moves her stronger limb forward with the cane.

The client holds the cane on the stronger side of her body.

A nurse is providing discharge teaching to a client about self administration of heparin. Which of the following should the nurse include? 1) Insert the needle at a 15° angle. 2) Aspirate for blood return prior to administration. 3) Administer the medication into the abdomen. 4) Massage the site following the injection.

Administer the medication into the abdomen.

A nurse is reviewing a client's fluid and electrolyte status. Which of the following findings should the nurse report to the provider? 1) BUN 15 mg/dL 2) Creatinine 0.8 mg/dL 3) Sodium 143 mEq/L 4) Potassium 5.4 mEq/L

Potassium 5.4 mEq/L

A nurse is using an open irrigation technique to irrigate a client's indwelling urinary catheter. Which of the following actions should the nurse take? 1) Place the client in a side-lying position. 2) Instill 15 mL of irrigation fluid into the catheter with each flush. 3) Subtract the amount of irrigant used from the client's urine output. 4) Perform the irrigation using a 20-mL syringe.

Subtract the amount of irrigant used from the client's urine output.

A nurse is assessing a client's readiness to learn about insulin self administration. Which if the following statements should the nurse identify as an indication that the client is ready to learn? 1) "I can concentrate best in the morning." 2) "It is difficult to read the instructions because my glasses are at home." 3) "I'm wondering why I need to learn this." 4) "You will have to talk to my wife about this."

"I can concentrate best in the morning."

A nurse is assessing a client who reports increased pain following physical therapy. Which of the following questions should the nurse ask when assessing the quality of the client's pain? 1) "Is your pain constant or intermittent?" 2) "What would you rate your pain on a scale of 0 to 10?" 3) "Does the pain radiate?" 4) "Is your pain sharp or dull?"

"Is your pain sharp or dull?"

A client who is postop is verbalizing pain as a 2. Which of the following statements should the nurse identify as an indication that the client understands the preop teaching she received about pain management? 1) "I think I should take my pain medication more often, since it is not controlling my pain." 2) "Breathing faster will help me keep my mind off of the pain." 3) "It might help me to listen to music while I'm lying in bed." 4) "I don't want to walk today because I have some pain."

"It might help me to listen to music while I'm lying in bed."

A nurse is caring for a client who has a respiratory infection. Which of the following techniques should the nurse use when performing nasotracheal suctioning for the client? 1) Insert the suction catheter while the client is swallowing. 2) Apply intermittent suction when withdrawing the catheter. 3) Place the catheter in a location that is clean and dry for later use. 4) Hold the suction catheter with her clean, nondominant hand.

Apply intermittent suction when withdrawing the catheter.

A nurse is caring for a client who has dementia. Which of the following interventions should the nurse take to minimize the risk for injury? 1) Use a bed exit alarm system. 2) Raise four side rails while the client is in bed. 3) Apply one soft wrist restraint. 4) Dim the lights in the client's room.

Use a bed exit alarm system.

A nurse is teaching a client and his family how to care for the client's tracheostomy at home. Which of the following instructions should the nurse include in the teaching? 1) Remove the outer cannula cautiously for routine cleaning. 2) Use tracheostomy covers when outdoors. 3) Use sterile technique when performing tracheostomy care at home. 4) Cleanse irritated skin with full-strength hydrogen peroxide.

Use tracheostomy covers when outdoors.

A nurse is assessing a client who has required bed rest for the past month. Which of the following findings should the nurse identify as an indication that the client has developed thrombophlebitis? 1) Bladder distention 2) Decreased blood pressure 3) Calf swelling 4) Diminished bowel sounds

Calf swelling

A nurse is admitting a new client. Which of the following actions should the nurse take while performing medication reconciliation? 1) Verify the client's name on their identification bracelet with the medication administration record. 2) Call the pharmacy to determine whether the client's medications are available. 3) Compare the client's home medications with the provider's prescriptions. 4) Place the client's home medication bottles in a secure location.

Compare the client's home medications with the provider's prescriptions.

A nurse is initiating a protective environment for a client who has had an allogeneic stem cell transplant. Which of the following precautions should the nurse plan for this client? 1) Make sure the client's room has at least six air exchanges per hour. 2) Make sure the client wears a mask when outside her room if there is construction in the area. 3) Place the client in a private room with negative-pressure airflow. 4) Wear an N95 respirator when giving the client direct care.

Make sure the client wears a mask when outside her room if there is construction in the area.

A nurse is caring for a client who is postoperative and is exhibiting signs of hemorrhagic shock. The nurse notifies the surgeon, who tells the nurse to continue to measure the client's vitals every 15 mins and to report back in 1 hr. Which of the following actions should the nurse take next? 1) Document the provider's statement in the medical record. 2) Complete an incident report. 3) Consult the facility's risk manager. 4) Notify the nursing manager.

Notify the nursing manager.

A nurse on a med surge unit is caring for a client who has a new Rx for wrist restraints. Which of the following actions should the nurse take? 1) Pad the client's wrist before applying the restraints. 2) Evaluate the client's circulation every 8 hr after application. 3) Remove the restraints every 4 hr to evaluate the client's status. 4) Secure the restraint ties to the bed's side rails.

Pad the client's wrist before applying the restraints.

A nurse is caring for a group of clients. Which of the following actions should the nurse take to prevent the spread of infection? 1) Carry a client's soiled linens out of the room in a mesh linen bag. 2) Place a client who has tuberculosis in a room with negative-pressure airflow. 3) Provide disposable plates and utensils for a client who is HIV-positive. 4) Dispose of a client's blood-saturated dressing in a trash bag inside a second trash bag.

Place a client who has tuberculosis in a room with negative-pressure airflow.

A nurse is planning to insert a peripheral IV catherter for an older adult client. Which of the following actions should the nurse plan to take? 1) Insert the catheter at a 45° angle. 2) Place the client's arm in a dependent position. 3) Shave excess hair from the insertion site. 4) Initiate IV therapy in the veins of the hand.

Place the client's arm in a dependent position.

A nurse is administering an otic medication to an older adult client. Which of the following actions should the nurse take to ensure that the medication reaches the inner ear? 1) Press gently on the tragus of the client's ear. 2) Pack a small piece of cotton deep into the client's ear canal. 3) Move the client's auricle down and back toward her head. 4) Tilt the client's head backward for 5 min.

Press gently on the tragus of the client's ear.

A nurse is reviewing evidence based practice principles about administration of oxygen therapy with a newly licensed nurse. Which of the following actions should the include? 1) Regulate the flow rate by aligning the rate with the top of the ball inside the flow meter. 2) Regulate oxygen via nasal cannula at a flow rate of no more than 6 L/min. 3) Make sure the reservoir bag of a partial rebreathing mask remains deflated. 4) Use petroleum jelly to lubricate the client's nares, face, and lips.

Regulate oxygen via nasal cannula at a flow rate of no more than 6 L/min.

A nurse is performing a home safety assessment for a client who is receiving supplemental oxygen. Which of the following observations should the nurse identify as proper safety protocol? 1) The client uses a wool blanket on their bed. 2) The client uses nonacetone nail polish remover. 3) The client stores an extra oxygen tank on its side under their bed. 4) The client has a weekly inspection checklist for oxygen equipment.

The client uses nonacetone nail polish remover.

A home health nurse is performing a follow up visit for a client who has a gastrostomy tube through which the receive intermittent feedings and medications. The client has recently developed diarrhea. Which of the following findings should the nurse identify as a possible cause of the diarrhea? 1) The client is receiving formula at room temperature. 2) The feedings infuse at a slow, continuous drip over 8 hr each night. 3) The client's caregiver washes out the feeding bag with warm water once every 24 hr. 4) The client's caregiver flushes the tubing with water before and after administering medications.

The client's caregiver washes out the feeding bag with warm water once every 24 hr.

A nurse is caring for a client who has a terminal illness and is approaching death. The client is SOB and has noisy respirations from secretions in their airway. Which of the following actions should the nurse take? 1) Turn the client every 2 hr. 2) Administer an antiemetic every 6 hr. 3) Hold oral care. 4) Increase the room's temperature.

Turn the client every 2 hr.

A nurse is caring for a client who has diarrhea due to shigella. Which of the following precautions should the nurse implement for this client? 1) Have the client wear a mask when receiving visitors 2) Limit the client's time with visitors to no more than 30 min per day. 3) Assign the client to a room with negative-pressure airflow exchange. 4) Wear a gown when caring for the client.

Wear a gown when caring for the client.

A nurse is preparing to apply a dressing for a client who has a stage 2 pressure injury. Which of the following types of dressings should the nurse use? 1) Alginate 2) Gauze 3) Transparent 4) Hydrocolloid

Hydrocolloid

A nurse is administering 1 L of 0.9% sodium chloride to a client who is postop and has a volume deficit. Which of the following changes should the nurse identify as an indication that the treatment was successful? 1) Increase in hematocrit 2) Increase in respiratory rate 3) Decrease in heart rate 4) Decrease in capillary refill time

Decrease in heart rate

A nurse is caring for a client who has a sodium level of 125 mEq/L. Which of the following findings should the nurse expect? 1) Numbness of the extremities 2) Bradycardia 3) Positive Chvostek's sign 4) Abdominal cramping

Abdominal cramping

A nurse is caring for a client who has herpes zoster & asks the nurse about the use of complementary and alternative therapies for pain control. The nurse should inform the client that his condition is a contraindication for which of the following therapies? 1) Biofeedback 2) Aloe 3) Feverfew 4) Acupuncture

Acupuncture