Fundamentals Practice Test A with NGN

A nurse is caring for a client who has an aggressive form of prostate cancer. The provider briefly discusses treatment options and leaves the client's room. When the nurse asks if the client would like to discuss any concerns, the client declines. Which of the following statements should the nurse make?

"I am available to talk if you should change your mind."

A nurse is caring for a client who has a terminal illness and is at the end of life. The nurse should recognize that which of the following statements by the client's partner indicates effective coping?

"I am relying on support from our family during this time."

A nurse is providing discharge instructions to a client who will be using a walker. Which of the following client statements indicates an understanding of the teaching?

"I will hire someone to trim the tree that hangs low over the stairs of my front porch."

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?

"Is your pain sharp or dull?"

A client who is postoperative is verbalizing pain as a 2 on a pain scale of 0 to 10. Which of the following statements should the nurse identify as an indication that the client understands the preoperative teaching she received about pain management?

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

A nurse is talking with an older adult client who is contemplating retirement. The client states, "I keep thinking about how much I enjoy my job. I'm not sure I want to retire." Which of the following responses should the nurse make?

"Let's talk about how the change in your job status will affect you."

A nurse is caring for a client who asks about the purpose of advance directives. Which of the following statements should the nurse make?

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

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?

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

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 emergency department and I had difficulty breathing?" Which of the following responses should the nurse make?

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

A nurse is evaluating teaching for a client who has heart failure. Which of the following 3 statements by the client indicates an understanding of the teaching? A nurse in a provider's clinic is caring for a client who has heart failure. Exhibit 1: Nurses' Notes: First Clinic Visit: Client arrives to clinic with report of increasing shortness of breath, fatigue, and weakness. States they get short of breath with minimal activity. Client is alert and oriented to person, place, and time. Moves all extremities well, follows simple commands. Sinus tachycardia. Pulses to lower extremities weak with +2 dependent edema present. Slightly labored respirations at rest. Chest with wheezes and crackles in the bases. Reports productive cough, especially during the overnight hours. Bowel sounds all present. Abdomen distended. Reports bowel movement this a.m. States voiding without difficulty, clear yellow urine. Teaching provided on nutrition therapy and adhering to a low-sodium diet, monitoring fluid intake, and lifestyle changes for heart failure. Provided medication teaching following provider's increase in furosemide dosage from 20 mg to 40 mg daily. Client to return in 2 weeks for follow-up. Second Clinic Visit: Client arrives for follow-up visit 2 weeks later. Client is alert and oriented to person, place, and time. Moves all extremities well, follows simple commands. Sinus rhythm. Pulses to lower extremities weak. +1 dependent edema present. Respirations even. Chest clear. Reports less coughing. Bowel sounds all present. Abdomen slightly distended. Reports last bowel movement previous evening. States voiding without difficulty, clear yellow urine. States urination has increased with increased dose of furosemide. Exhibit 2: Vital Signs: First Clinic Visit: Temperature 36.7° C (98° F), Heart rate 106/min, Respirations 26/min, BP 162/88 mm Hg, Oxygen saturation 93% on room air, Weight 83.9 kg (185 lb) Second Clinic Visit: Temperature 36.7° C (98° F), Heart rate 86/min, Respirations 22/min, BP 142/78 mm Hg, Oxygen saturation 94% on room air, Weight 81.6 kg (180 lb)

- "I am limiting my sodium intake to 2 grams daily" - "I am eating fewer potato chips and more fruit for snacks" - "I know to call my doctor if I gain 3 pounds or more in 2 days"

Select the 3 findings that require follow-up. A nurse is caring for a client who has COPD. Exhibit 1: Nurses' Notes: 1000: Client admitted with a productive cough with thick yellow sputum. Breath sounds with crackles heard in left upper lobe and decreased breath sounds at bases bilaterally. Exhibit 2: Vital Signs: 1000: Temperature 38.6° C (101.5° F), BP 114/56 mm Hg, Heart rate 99/min, Respirations 32/min, Oxygen saturation 85% on room air Exhibit 3: Diagnostic Results: 1200:Chest x-ray shows lung hyperinflation and left upper lobe pneumonia.

- Breath sounds - Oxygen saturation - Temperature

Select the 3 tasks the nurse should delegate to an assistive personnel (AP). A nurse is caring for a client who has pancreatitis. Exhibit 1: Nurses' Notes: 1000: Client states, "I am unable to eat anything without vomiting." Client reports pain in left upper quadrant of abdomen that radiates to their back. States that pain is a "7" on a 0 to 10 pain scale. Bruising noted on client's abdomen. Client is pale and diaphoretic. Provider prescribed blood work, abdominal CT, and NG tube insertion with low-intermittent decompression. IV fluids started and infusing in left peripheral IV site. Exhibit 2: Vital Signs: 1000: BP 96/52 mm Hg, Heart rate 110/min, Respirations 22/min, Temperature 38.4° C (101.1° F), Oxygen saturation 92% on room air Exhibit 3: Prescriptions: 1100: CT of abdomen, NG tube to low wall suction, Serum amylase level

- Document the client's vital signs - Measure the client's intake and output - Transfer the client from wheelchair to bed

The nurse is providing teaching for the client who has diarrhea. Select the 4 instructions that the nurse should include in the teaching. A nurse in a provider's clinic is caring for a client who has diarrhea. Exhibit 1: Vital Signs: Temperature 36.2° C (97.2° F), Pulse rate 116/min, Respiratory rate 24/min, BP 102/68 mm Hg, Oxygen saturation 95%Weight 52.2 kg (115 lb) Exhibit 2: Nurses' Notes: 1000: Client reports diarrhea for the past 5 days with approximately 8 liquid stools a day. Woke up this morning feeling dizzy. States, "I felt like I was going to pass out." Client was seen 7 days ago for sinus infection and was prescribed amoxicillin. Weight at previous visit was 56.2 kg (124 lb). Denies bloody or black stools. 1030: Blood collected for CBC, basic metabolic profile (BMP); stool collected for C. difficile; urine collected for urinalysis. 1100: Informed client that the office will call with results of laboratory findings; prescription for loperamide provided, instructed to discontinue amoxicillin; instructed to drink electrolyte solution; teaching provided for managing diarrhea. Exhibit 3: Physical Examination: 1015: Oriented to person, place, and time; lethargic, reports headache. Tachycardia, hypotension, thready pulse, dry mucous membranes, tenting present. Respirations slightly labored, chest clear. Bowel sounds x 4 quadrants hyperactive. Reports urine is dark, minimal amount.

- Eat probiotic foods, such as yogurt. - Avoid alcohol while experiencing diarrhea. - Avoid caffeine while experiencing diarrhea. - Follow a low-fiber diet.

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.)

- Pupil clarity - Visual fields - Visual acuity

The nurse is assessing the client. Which of the following actions should the nurse take? Select all that apply. A nurse is caring for a client who has a peripheral IV inserted for fluid replacement. Exhibit 1: Nurses' Notes: Day 1: Lactated Ringer's at 100 mL/hr infusing into a 20-guage IV catheter in left hand. IV dressing dry and intact. IV site without redness or swelling. IV fluid infusing well. Day 2: IV site edematous. Skin surrounding catheter site taut, blanched, and cool to touch. IV fluid not infusing.

- Stop the IV infusion. - Elevate the client's left arm. - Apply heat to the client's left arm.

Click to highlight the assessment findings below that the nurse should report to the provider. A nurse is caring for a client who is postoperative following abdominal surgery. Exhibit 1: Nurses' Notes: 1100: Client received from PACU; initial vital signs recorded. Client drowsy but responds to verbal stimuli. Client is oriented to person, place, and time. Client can move all extremities. Hypoactive bowel sounds. Abdominal dressing intact with drainage noted and marked. Indwelling urinary catheter in place and draining yellow urine. Infusing lactated Ringer's at 100 mL/hr to the right forearm. Client positioned for comfort, side rails raised x 2, call light in the client's reach. 1115: Provider prescriptions reviewed. 1200: Upon waking, client reports nausea and rates pain as a 6 on a scale of 0 to 10. Abdominal dressing intact, no further drainage noted. Urine output of 15 mL since 1100. Morphine 4 mg IV bolus and metoclopramide 10 mg IV bolus administered. 1230: Client reports relief from nausea, but not pain. Client rates pain as an 8 on a scale of 0 to 10. No additional urine output since 1200. Repositioned client for comfort. Exhibit 2: MAR: Morphine 4 mg IV bolus every 4 hr PRN pain, Metoclopramide 10 mg IV bolus every 6 hr PRN nausea and vomiting Exhibit 3: Vital Signs: 1100:Temperature 36.2° C (97.2° F), Heart rate 76/min, Respirations 18/min, BP 122/68 mm Hg, Oxygen saturation 95% on room air 1200: Temperature 36.8° C (98.2° F), Heart rate 116/min, Respirations 20/min, BP 112/68 mm Hg, Oxygen saturation 93% on room air

- Urinary output - Reported pain level - Vital signs

The nurse is placing the client on isolation precautions. Which of the following interventions should the nurse include? Select all that apply. A nurse is admitting a client to a health care facility. Exhibit 1: Nurses' Notes: 1100: Client reports fever, chills, cough, and night sweats for past 2 weeks. Client has recently traveled outside of the country. Lethargic, but oriented to person, place, and time. Crackles heard in lower lobes of lungs upon auscultation. Cough is productive with small amounts of blood. Reports tightness in chest and pain when coughing. Reports losing 5 lb in the last week. Has no appetite and is nauseated. Obtained blood work, chest x-ray, and sputum culture as prescribed. Exhibit 2: Vital Signs: 1100: BP 138/72 mm Hg, Heart rate 80/min, Respirations 22/min, Temperature 38.3° C (101.1° F), Oxygen saturation 90% on room air Exhibit 3: Diagnostic Results: 1400: Chest x-ray positive for inflammation and infiltrates in upper lobes, QuantiFERON-TB positive (negative), Tuberculosis culture positive (negative)

- Wear an N95 mask when caring for the client - Place a container for soiled linens inside the client's room - Place the client in a negative airflow room - Remove mask after exiting the client's room

A nurse is preparing to administer 0.9% sodium chloride 750 mL IV to infuse over 7 hr. The nurse should set the infusion pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

107 mL/hr

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?

A mole with an asymmetrical appearance.

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 this condition is a contraindication for which of the following therapies?

Acupuncture

A nurse is providing discharge teaching to a client about self-administering heparin. Which of the following instructions should the nurse include in the teaching?

Administer the medication into the abdomen.

A nurse is preparing to administer enoxaparin subcutaneously to a client. Which of the following actions should the nurse take?

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

A nurse is preparing an education program for staff about advocacy. Which of the following information should the nurse include?

Advocacy ensures clients' safety, health, and rights.

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?

Ask another nurse to observe the medication wastage.

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?

Check the client for injuries.

A nurse is admitting a new client. Which of the following actions should the nurse take while performing medication reconciliation?

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

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?

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

A nurse is preparing to apply a dressing for a client who has a stage 2 pressure injury. Which of the following types of dressing should the nurse use?

Hydrocolloid

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?

Contact precautions

A nurse is administering 1 L of 0.9% sodium chloride to a client who is postoperative and has fluid volume deficit. Which of the following changes should the nurse identify as an indication that the treatment was successful?

Decrease in heart rate

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 actions is the nurse's priority?

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

A nurse in a provider's office is assessing the deep tendon reflexes of a client. Which of the following images should the nurse identify as indicating the correct technique for eliciting the client's patellar reflex?

Image accessing the patella. (Kneecap)

A nurse is caring for a client who has pharyngeal diphtheria. Which of the following types of transmission precautions should the nurse initiate?

Droplet

A nurse is admitting a client who is having an exacerbation of heart failure. In planning this client's care, when should the nurse initiate discharge planning?

During the admission process

A nurse is assessing four adult clients. Which of the following physical assessment techniques should the nurse use?

Ensure the bladder of the blood pressure cuff surrounds 80% of the client's arm.

A nurse is caring for a child who has a prescription for a blood transfusion. The child's parents have refused the treatment due to their religious beliefs. Which of the following actions should the nurse take?

Examine personal values about the issue.

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?

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 following a knee arthroplasty and requires the use of thigh-length sequential compression sleeves. Which of the following actions should the nurse take?

Make sure two fingers can fit under the sleeves.

A nurse is auscultating the anterior chest of a client who was newly admitted to a medical-surgical unit. Listen to the audio clip of what the nurse auscultates through the stethoscope and identify the type of breath sounds.

Normal breath sounds

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 vital signs every 15 min and to report back in 1 hr. Which of the following actions should the nurse take next?

Notify the nursing manager.

A nurse on a medical-surgical unit is caring for a client who has a new prescription for wrist restraints. Which of the following actions should the nurse take?

Pad the client's wrist before applying the restraints.

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?

Place the client's arm in a dependent position.

A nurse is reviewing a client's fluid and electrolyte status. Which of the following findings should the nurse report to the provider?

Potassium 5.4 mEq/L

A nurse is caring for a client who is expressing anger about his diagnosis of colorectal cancer. Which of the following actions should the nurse take?

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

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 nurse include?

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

Complete the following sentence by using the list of options. A nurse is caring for a client who is receiving a unit of packed RBCs. Exhibit 1: Nurses' Notes: 0800: Packed RBCs initiated by the charge nurse through an 18-guage peripheral IV to infuse over 2 hr. 0815: Client reports itching and anxiety. Client's face is flushed and has hives. Exhibit 2: Vital Signs: 0800: BP 112/64 mm Hg, Heart rate 80/min, Respirations 18/min, Temperature 37.1° C (98.8° F), Oxygen saturation 97% on room air 0815: BP 106/54 mm Hg, Heart rate 100/min, Respirations 22/min, Temperature 37° C (98.6° F), Oxygen saturation 95% on room air

The client has manifestations of allergic reaction as evidenced by the client's itching.

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?

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

A nurse is talking with the partner of a client who has dementia. The client's partner expresses frustration about finding time to manage household responsibilities while caring for their partner. The nurse should identify that the partner is experiencing which of the following types of role-performance stress?

Role overload

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?

Situation, background, assessment, and recommendation (SBAR)

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?

Stand close to the cabinet when lifting it.

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?

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

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?

The client identifies the location of a fire extinguisher.

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.

The first step is to obtain the death pronouncement from the provider. Next, the nurse should remove tubes and indwelling lines prior to cleansing the client's body. After cleansing, the nurse should ask the family members if they wish to view the body. Finally, the nurse should place a name tag on the body before transfer.

Complete the following sentence by using the list of options. A nurse is caring for a client who has a new diagnosis of seizure disorder. Exhibit 1: Nurses' Notes: 0800: Client awake, alert, oriented to person, place, and time. Preparing for discharge today. No seizure activity recorded during the night. Discharge teaching provided to client and partner regarding a new prescription for carbamazepine. Taught importance of taking medication twice daily as prescribed, not to miss a dose, and not to double a dose if one is missed. Advised client to avoid grapefruit and grapefruit juice while taking carbamazepine. Reminded client that follow-up laboratory tests and eye examinations will be necessary while on this medication. Client and partner verbalized understanding of all medication teaching. 0900: On entry into client's room with discharge papers, client was found on the floor seizing. Call button pressed to ask for additional help. Exhibit 2: MAR: Carbamazepine ER 200 mg PO twice per day, Lorazepam 4 mg IV bolus PRN seizure activity, may repeat after 10 to 15 min

The nurse should first address the client's physical safety followed by the client's positioning.

Complete the following sentence by using the list of options. A nurse in an emergency department is caring for a client. Exhibit 1: Physical Examination: 1200: Influenza with nausea, vomiting, and diarrhea for 3 days. Client is tachycardic, hypotensive, and tachypneic, with weak pulses, dry mucous membranes, poor turgor, and oliguria. Plan: Admit for IV fluids. Exhibit 2: Vital Signs: 1200: Temperature 38.4° C (101.1° F), Pulse rate 126/min, Respirations 28/min, BP 92/54 mm Hg, Oxygen saturation 93% Exhibit 3: Nurses' Notes: 1900: Client is disoriented, confused. Client attempting to get out of bed without assistance and states, "I'm going home." Returned to bed, attempted to reorient to time, place, and circumstances. Call placed to client's family, no answer, message left. 1915: Client remains disoriented. Attempting to pull out IV line. Call was returned by client's family. Updated them on situation. Exhibit 4: MAR: Dextrose 5% in 0.45% sodium chloride IV at 125 mL/hr, Promethazine 25 mg IV bolus every 4 to 6 hr PRN nausea and vomiting, Diphenoxylate 5 mg PO four times daily, Acetaminophen 625 mg PO every 6 hr PRN temperature greater than 38.6° C (101.5° F)

The nurse should first review medications that might cause confusion followed by using other methods to keep the client safe.

Complete the following sentence by using the list of options. A nurse is caring for a client who has pneumonia. Exhibit 1: Vital Signs: 0800: Heart rate 109/min, Respirations 26/min, BP 125/65 mm Hg, Temperature 39.2° C (102.6° F), Oxygen saturation 95% 1200: Heart rate 94/min, Respirations 18/min, BP 115/65 mm Hg, Temperature 37.8° C (100° F), Oxygen saturation 96% Exhibit 2: MAR: 0.45% sodium chloride IV at 125 mL/hr, Vancomycin 1 g intermittent IV bolus every 12 hr, Acetaminophen 650 mg PO every 6 hr PRN temperature greater than 38.3° C (101° F), Codeine 20 mg PO every 4 hr PRN cough Exhibit 3: Nurses' Notes: 0800: Oriented to person, place, and time. Appears fatigued. Diaphoretic, febrile. Reports not sleeping well last night due to "coughing a lot." Moves all extremities well. Tachycardia. All pulses palpable. Reports chest discomfort with coughing. Respirations 26/min, shallow. Auscultation reveals diminished breath sounds and bilateral crackles. Pulse oximetry 95% on O2 2 L via nasal cannula. Hypoactive bowel sounds present in all four quadrants. States tolerating diet with no nausea or vomiting but has no appetite. Client states voiding using the bedside commode with no difficulty. Output of 500 mL clear, yellow urine flushed. IV infusing to right arm, no noted redness or irritation at site. Acetaminophen administered for temperature. 1200: States feeling better following administration of acetaminophen. Vancomycin infusion started. Client voices no discomfort at this time. 1300: Client reports intense pain at IV catheter site. Area taut, blanched, cool to touch with edema present. IV vancomycin discontinued and catheter removed. Provider notified.

The nurse should identify that the client might be experiencing extravasation as evidenced by the client's IV catheter site.

A nurse is caring for a client who has a terminal illness and is approaching death. The client is short of breath and has noisy respirations from secretions in their airway. Which of the following actions should the nurse take?

Turn the client every 2 hr.

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 to the client?

Use a bed exit alarm system.

A nurse is planning strategies to manage time effectively for client care. Which of the following strategies should the nurse implement?

Use the planning step of the nursing process to prioritize client care delivery.

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?

Use tracheostomy covers when outdoors.