Fundamentals Practice Test A

A nurse is preparing a heparin infusion for a client who was hospitalized with deep-vein thrombosis. The order reads: 25,000 units of heparin in 250 mL of 0.9% sodium chloride to infuse at 800 units/hr. At what rate should the nurse set the infusion pump? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

8 mL/hr

A nurse is assessing a client who has been on bed rest for the past month. Which of the following findings should the nurse identify as an indication that the client has developed thrombophlebitis? A) Bladder distention B) Decreased blood pressure C) Calf swelling D) Diminished bowel sounds

C) Calf swelling

A nurse in a long-term care facility is planning to perform hygiene care for a new resident. Which of the following assessment questions is the nurse's priority before beginning this procedure? A) "When do you usually bathe, in the morning or in the evening?" B) "Do you prefer a bath or a shower?" C) "At what temperature do you prefer your bath water?" D) "Are you able to help with your hygiene care?"

D) "Are you able to help with your hygiene care?"

A nurse is preparing to transfer a client who has right-sided weakness from the bed to a chair. In what order should the nurse take the following actions to assist the client? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.) 1) Ask the client if he can bear weight 2) Use the stand-and-pivot technique to move the client to the chair 3) Position the chair on the left side of the bed 4) Have the client sit and dangle his feet at the bedside

1) Ask the client if he can bear weight 3) Position the chair on the left side of the bed 4) Have the client sit and dangle his feet at the bedside 2) Use the stand-and-pivot technique to move the client to the chair

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

B) 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? A) Press gently on the tragus of the client's ear. B) Pack a small piece of cotton deep into the client's ear canal. C) Move the client's auricle down and back toward her head. D) Tilt the client's head backward for 5 min.

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

A nurse is caring for a client who is terminally ill. Which of the following statements should the nurse identify as an indication that the client's family member is coping effectively with the situation? A) "We are not worried. We still have hope that everything will be okay." B) "This is a difficult time, but we are helping each other through this." C) "After he comes home, we can plan our family reunion." D) "We don't need to talk about funeral arrangements at this time."

B) "This is a difficult time, but we are helping each other through this."

A nurse manager is overseeing the care on a unit. Which of the following situations should the nurse manager identify as a violation of HIPAA guidelines? A) A nurse who is caring for a client reviews the client's medical chart with the nursing student who is working with the nurse. B) A nurse asks a nurse from another unit to assist with her documentation. C) A nurse who is caring for a client returns a call to the client's durable power of attorney for health care designee to discuss the client's care. D) A nurse discusses a client's status with the physical therapist that is caring for the client at the client's bedside.

B) A nurse asks a nurse from another unit to assist with her documentation.

A nurse is caring for a client who reports pain. When documenting the quality of the client's pain on an initial pain assessment, the nurse should record which of the following client statements? A) "I'm having mild pain." B) "The pain is like a dull ache in my stomach." C) "I notice that the pain gets worse after I eat." D) "The pain makes me feel nauseous."

B) "The pain is like a dull ache in my stomach."

A nurse is assisting a client who is postoperative with the use of an incentive spirometer. Into which of the following positions should the nurse place the client? A) Side-lying B) Supine C) Semi-Fowler's D) Trendelenburg

C) Semi-Fowler's

A nurse is planning an education session for an older adult client who has just learned that she has type 2 diabetes mellitus. Which of the following strategies should the nurse plan to use with this client? A) Allow extra time for the client to respond to questions. B) Expect the client to have difficulty understanding the information. C) Avoid references to the client's past experiences. D) Keep the learning session private and one-on-one.

A) Allow extra time for the client to respond to questions.

A nurse is caring for a client who has terminal liver cancer. Which of the following statements should the nurse identify as an indication that the client is experiencing spiritual distress? A) "What could I have done to deserve this illness?" B) "I blame medical science for not curing me." C) "Where is my daughter at a time like this?" D) "Will I ever begin to feel in charge of my life again?"

A) "What could I have done to deserve this illness?"

A nurse is admitting a client who has varicella. Which of the following types of transmission precautions should the nurse initiate? A) Airborne B) Droplet C) Contact D) Protective environment

A) Airborne

A nurse is preparing to administer an injection of an opioid medication to a client. The nurse draws out 1 mL of the medication from a 2 mL vial. Which of the following actions should the nurse take? A) Ask another nurse to observe the medication wastage. B) Notify the pharmacy when wasting the medication. C) Lock the remaining medication in the controlled substances cabinet. D) Dispose of the vial with the remaining medication in a sharps container.

A) Ask another nurse to observe the medication wastage.

A nurse is administering IV fluid to an older adult client. The nurse should perform which priority assessment to monitor for adverse effects? A) Auscultate lung sounds. B) Measure urine output. C) Monitor blood pressure readings. D) Monitor serum electrolyte levels.

A) Auscultate lung sounds.

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? A) Check the client for injuries. B) Move hazardous objects away from the client. C) Notify the provider. D) Ask the client to describe how she felt prior to the fall.

A) Check the client for injuries.

A nurse is assessing an adult client who has been immobile for the past 3 weeks. The nurse should identify that which of the following findings requires further intervention? A) Erythema on pressure points B) Lower-extremity pulse strength of 2+ C) Fluid intake of 3,000 mL per day D) A bowel movement every other day

A) Erythema on pressure points

A nurse is preparing to administer 0.5 mL of oral single-dose liquid medication to a client. Which of the following actions should the nurse take? A) Gently shake the container of medication prior to administration. B) Transfer the medication to a medicine cup. C) Place the client in a semi-Fowler's position prior to medication administration. D) Verify the dosage by measuring the liquid before administering it.

A) Gently shake the container of medication prior to administration.

A nurse is teaching an older adult client who is at risk for osteoporosis about beginning a program of regular physical activity. Which of the following types of activity should the nurse recommend? A) Walking briskly B) Riding a bicycle C) Performing isometric exercises D) Engaging in high-impact aerobics

A) Walking briskly

A nurse is caring for a client who asks about the purpose of advance directives. Which of the following statements should the nurse make? A) "They allow the court to overrule an adult client's refusal of medical treatment." B) "They indicate the form of treatment a client is willing to accept in the event of a serious illness." C) "They permit a client to withhold medical information from health care personnel." D) "They allow health care personnel in the emergency department to stabilize a client's condition."

B) "They indicate the form of treatment a client is willing to accept in the event of a serious illness."

A nurse has accepted a verbal prescription for three tenths of a milligram of levothyroxine IV stat for a client who has myxedema coma. How should the nurse transcribe the dosage of this medication in the client's medical record? A) .3 mg B) 0.3 mg C) 0.30 mg D) 3/10 mg

B) 0.3 mg

A nurse is caring for a client who is postoperative and refuses to use an incentive spirometer following major abdominal surgery. Which of the following is the nurse's priority action? A) Request that a respiratory therapist discuss the technique for incentive spirometry. B) Determine the reasons why the client is refusing to use the incentive spirometer. C) Document the client's refusal to participate in health restorative activities. D) Administer a pain medication to the client.

B) Determine the reasons why the client is refusing to use the incentive spirometer.

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.) A) Lacrimal apparatus B) Pupil clarity C) Appearance of bulbar conjunctivae D) Visual fields E) Visual acuity

B) Pupil clarity D) Visual fields E) Visual acuity

A nurse is preparing a change-of-shift report. Which of the following tools or documents should the nurse use to communicate continuity of care? A) Critical pathway B) Situation, background, assessment, and recommendation (SBAR) C) Transfer report D) Medication administration record (MAR)

B) Situation, background, assessment, and recommendation (SBAR)

A nurse is caring for a client who requires a 24-hr urine collection. Which of the following statements by the client indicates an understanding of the teaching? A) "I had a bowel movement, but I was able to save the urine." B) "I have a specimen in the bathroom from about 30 minutes ago." C) "I flushed what I urinated at 7:00 a.m. and have saved all urine since." D) "I drink a lot, so I will fill up the bottle and complete the test quickly."

C) "I flushed what I urinated at 7:00 a.m. and have saved all urine since."

A nurse is caring for a client who has a prescription for wound irrigation. Which of the following actions should the nurse take? A) Wear sterile gloves when removing the old dressing. B) Warm the irrigation solution to 40.5° C (105° F). C) Cleanse the wound from the center outward. D) Use a 20-mL syringe to irrigate the wound.

C) Cleanse the wound from the center outward.

A nurse is providing care to four clients. Which of the following situations requires the nurse to complete an incident report? A) A nurse tied a client's restraint straps to the moveable part of the bed frame. B) An assistive personnel placed a surgical mask on a client who has tuberculosis before transporting her to radiology. C) A nurse administers a medication to a client 30 min before the dose is due. D) A client who has an IV infusion pump receives an additional 250 mL of IV fluid.

D) A client who has an IV infusion pump receives an additional 250 mL of IV fluid.

A nurse is caring for a client who requires an NG tube for stomach decompression. Which of the following actions should the nurse take when inserting the NG tube? A) Position the client with the head of the bed elevated to 30° prior to insertion of the NG tube. B) Remove the NG tube if the client begins to gag or choke. C) Apply suction to the NG tube prior to insertion. D) Have the client take sips of water to promote insertion of the NG tube into the esophagus.

D) Have the client take sips of water to promote insertion of the NG tube into the esophagus.

A nurse is caring for a client who has limited mobility in his lower extremities. Which of the following actions should the nurse take to prevent skin breakdown? A) Place the client in high-Fowler's position. B) Increase the client's intake of carbohydrates. C) Massage reddened areas with unscented lotion. D) Have the client use a trapeze bar when changing position.

D) Have the client use a trapeze bar when changing position.

A nurse is reviewing practice guidelines with a group of newly licensed nurses. Which of the following interventions should the nurse include that is within the RN scope of practice? A) Insert an implanted port. B) Close a laceration with sutures. C) Place an endotracheal tube. D) Initiate an enteral feeding through a gastrostomy tube.

D) Initiate an enteral feeding through a gastrostomy tube.

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

D) Potassium 5.4 mEq/L

A nurse is caring for a client who is expressing anger over his diagnosis of colorectal cancer. Which of the following actions should the nurse take? A) Discuss the risk factors for colon cancer. B) Focus teaching on what the client will need to do in the future to manage his illness. C) Provide the client with written information about the phases of loss and grief. D) Reassure the client that this is an expected response to grief.

D) Reassure the client that this is an expected response to grief.

A nurse manager is preparing to review medication documentation with a group of newly licensed nurses. Which of the following statements should the nurse manager plan to include in the teaching? A) "Use the complete name of the medication magnesium sulfate." B) "Delete the space between the numerical dose and the unit of measure." C) "Write the letter U when noting the dosage of insulin." D) "Use the abbreviation SC when indicting an injection."

A) "Use the complete name of the medication magnesium sulfate."

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

A) "I can concentrate best in the morning."

A nurse is caring for a client who has a prescription for 5 units of regular insulin and 10 units of NPH insulin to mix together and administer subcutaneously. Determine the correct order of steps for this procedure. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.) 1) Inject 5 units of air into the bottle of regular insulin 2) Withdraw the correct dose of NPH insulin from the bottle 3) Inject 10 units of air into the bottle of NPH insulin 4) Withdraw the correct dose of regular insulin from the bottle

3) Inject 10 units of air into the bottle of NPH insulin 1) Inject 5 units of air into the bottle of regular insulin 4) Withdraw the correct dose of regular insulin from the bottle 2) Withdraw the correct dose of NPH insulin from the bottle

A nurse is caring for a client receiving fluid through a peripheral IV catheter. Which of the following findings at the IV site should the nurse identify as infiltration? A) Purulent exudate B) Warmth C) Skin blanching D) Bleeding

C) Skin blanching

A nurse is performing a peripheral vascular assessment for a client. When placing the bell of the stethoscope on the client's neck, she hears the following sound. This sound indicates which of the following? (Click on the audio button to listen to the clip.) A) Narrowed arterial lumen B) Distended jugular veins C) Impaired ventricular contraction D) Asynchronous closure of the aortic and pulmonic valves

A) Narrowed arterial lumen

A nurse is caring for a client who has tuberculosis. Which of the following actions should the nurse take? (Select all that apply.) A) Place the client in a room with negative-pressure airflow. B) Wear gloves when assisting the client with oral care. C) Limit each visitor to 2-hr increments. D) Wear a surgical mask when providing client care. E) Use antimicrobial sanitizer for hand hygiene.

A) Place the client in a room with negative-pressure airflow. B) Wear gloves when assisting the client with oral care. E) Use antimicrobial sanitizer for hand hygiene.

A nurse is reviewing protocol in preparation for suctioning secretions from a client who has a new tracheostomy. Which of the following actions should the nurse plan to take? A) Use a resuscitation bag with 80% oxygen prior to the procedure. B) Select a suction catheter that is half the size of the lumen. C) Place the end of the suction catheter in water-soluble lubricant. D) Adjust the wall suction apparatus to a pressure of 170 mm Hg.

B) Select a suction catheter that is half the size of the lumen.

A nurse is caring for a client who has an NG tube and is receiving intermittent feedings through an open system. Which of the following actions should the nurse take first? A) Rinse the feeding bag with water between feedings. B) Tell the client to keep the head of the bed elevated at least 30°. C) Make sure the enteral formula is at room temperature. D) Wipe the top of the formula can with alcohol.

B) Tell the client to keep the head of the bed elevated at least 30°.

A nurse is caring for a client who is refusing a blood transfusion for religious reasons. The client's partner wants the client to have the blood transfusion. Which of the following actions should the nurse take? A) Ask the client to consider a direct donation. B) Withhold the blood transfusion. C) Request a consultation with the ethics committee. D) Ask the client's family to intervene.

B) Withhold the blood transfusion.

A nurse in a surgical suite notes documentation on a client's medical record that he has a latex allergy. In preparation for the client's procedure, which of the following precautions should the nurse take? A) Ensure sterilization of nondisposable items with ethylene oxide. B) Wrap monitoring cords with stockinette and tape them in place. C) Cleanse latex ports on IV tubing with chlorhexidine before injecting medication. D) Wear hypoallergenic latex gloves that contain powder.

B) Wrap monitoring cords with stockinette and tape them in place.

A nurse is giving discharge instructions to a client who will require oxygen therapy at home. Which of the following statements should the nurse identify as an indication that the client understands how to manage this therapy at home? A) "I'll make sure that, when my friend comes by, she smokes at least 6 feet away from my oxygen tank." B) "I'll use a woolen blanket if I get chilly while I'm using my oxygen." C) "I'll check the wires and cables on my TV to make sure they are in good working order." D) "I'll lay my oxygen tank down on the floor when the grandchildren visit so they don't knock it over."

C) "I'll check the wires and cables on my TV to make sure they are in good working order."

A nurse in a clinic is caring for a middle adult client who states, "The doctor says that, since I am at an average risk for colon cancer, I should have a routine screening. What does that involve?" Which of the following responses should the nurse make? A) "I'll get a blood sample from you and send it for a screening test." B) "Beginning at age 60, you should have a colonoscopy." C) "You should have a fecal occult blood test every year." D) "The recommendation is to have a sigmoidoscopy every 10 years."

C) "You should have a fecal occult blood test every year."

A nurse is performing a Romberg's test during the physical assessment of a client. Which of the following techniques should the nurse use? A) Touch the face with a cotton ball. B) Apply a vibrating tuning fork to the client's forehead. C) Have the client stand with her arms at her side and her feet together. D) Perform direct percussion over the area of the kidneys.

C) Have the client stand with her arms at her side and her feet together.

A nurse is completing an admission assessment for a client who reports vomiting and diarrhea for the past 3 days. Which of the following assessment findings should the nurse expect? A) Neck vein distention B) Urine specific gravity 1.010 C) Rapid heart rate D) Blood pressure 144/82 mm Hg

C) Rapid heart rate

A nurse is caring for a client who requires bed rest and has a prescription for antiembolic stockings. Which of the following actions should the nurse take? A) Apply the stockings so the creases are on the front side of the leg. B) Apply the stockings while the client's legs are in a dependent position. C) Remove the stockings at least once per shift. D) Remove the stockings while the client is sitting in a reclining chair.

C) Remove the stockings at least once per shift.

A nurse is talking with the partner of an older adult male client who has dementia. The client's partner expresses frustration about finding time to manage household responsibilities while caring for his partner. The nurse should identify that he is going through which of the following types of role-performance stress? A) Role ambiguity B) Sick role C) Role overload D) Role conflict

C) Role overload

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? A) Place the client in a side-lying position. B) Instill 15 mL of irrigation fluid into the catheter with each flush. C) Subtract the amount of irrigant used from the client's urine output. D) Perform the irrigation using a 20-mL syringe.

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

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

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

A nurse is reviewing a client's medication prescription, which reads, "digoxin 0.25 by mouth every day." Which of the following components of the prescription should the nurse question? A) The medication B) The route C) The dose D) The frequency

C) The dose

A nurse is caring for a client who is reporting difficulty falling asleep. Which of the following measures should the nurse recommend? A) Drink a cup of hot cocoa before bedtime. B) Exercise 1 hr before going to bed. C) Use progressive relaxation techniques at bedtime. D) Reflect on the day's activities before going to bed.

C) Use progressive relaxation techniques at bedtime.

A nurse is caring for a client who has herpes zoster and 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? A) Biofeedback B) Aloe C) Feverfew D) Acupuncture

D) Acupuncture

A nurse is caring for a client who is having difficulty breathing. The client is lying in bed with a nasal cannula delivering oxygen. Which of the following interventions should the nurse take first? A) Suction the client's airway. B) Administer a bronchodilator. C) Increase the humidity in the client's room. D) Assist the client to an upright position.

D) Assist the client to an upright position.

A nurse is admitting a client who has an abdominal wound with a large amount of purulent drainage. Which of the following types of transmission precautions should the nurse initiate? A) Protective environment B) Airborne precautions C) Droplet precautions D) Contact precautions

D) Contact precautions

A nurse is caring for a client who has had his diet prescription changed to a mechanical soft diet. Which of the following food items should the nurse remove from the client's breakfast tray? A) Tomato juice B) Bananas C) Pancakes D) Eggs

D) Eggs

A nurse is preparing to administer multiple medications to a client who has an enteral feeding tube. Which of the following actions should the nurse plan to take? A) Dissolve each medication in 5 mL of sterile water. B) Draw up medications together in the syringe. C) Push the syringe plunger gently when feeling resistance. D) Flush the tube with 15 mL of sterile water.

D) Flush the tube with 15 mL of sterile water.

A charge nurse is discussing the responsibility of nurses caring for clients who have a Clostridium difficile infection. Which of the following information should the nurse include in the teaching? A) Assign the client to a room with a negative air-flow system. B) Use alcohol-based hand sanitizer when leaving the client's room. C) Clean contaminated surfaces in the client's room with a phenol solution. D) Have family members wear a gown and gloves when visiting.

D) Have family members wear a gown and gloves when visiting.

A nurse is lifting a bedside cabinet to move it closer to a client who is sitting in a chair. To prevent self-injury, which of the following actions should the nurse take when lifting this object? A) Bend at the waist. B) Keep his feet close together. C) Use his back muscles for lifting. D) Stand close to the cabinet when lifting it.

D) Stand close to the cabinet when lifting it.

A nurse is planning care to improve self-feeding for a client who has vision loss. Which of the following interventions should the nurse include in the plan of care? A) Tell the client which food she should eat first. B) Provide small-handle utensils for the client. C) Thicken liquids on the client's tray. D) Use a clock pattern to describe food on the client's plate.

D) Use a clock pattern to describe food on the client's plate.