1. Fundamentals A
1. 1.ID: 310989309
An elderly client with a fractured left hip is on strict bedrest. Which nursing measure is essential to
the
... [Show More] client's nursing care?
A. Massage any reddened areas for at least five minutes.
B. Encourage active range of motion exercises on extremities.
C. Position the client laterally, prone, and dorsally in sequence.
D. Gently lift the client when moving into a desired position. Correct
2. 2.ID: 311018751
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. Correct
C. Administer the medications as prescribed.
D. Crush the tablets and dissolve in sterile water.
3. 3.ID: 310953495
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 aroundtheclock schedule for administration of
analgesics. Correct
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 medicationfree period so that the client can do daily activities.
4. 4.ID: 310965989
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?
A. Loosen the right wrist restraint. Correct
B. Apply a pulse oximeter to the right hand.
C. Compare hand color bilaterally.
D. Palpate the right radial pulse.
5. 5.ID: 310959857
The nurse is assessing the nutritional status of several clients. Which client has the greatest
nutritional need for additional intake of protein?
A. A collegeage track runner with a sprained ankle.
B. A lactating woman nursing her 3dayold infant. Correct
C. A schoolaged child with Type 2 diabetes.
D. An elderly man being treated for a peptic ulcer.
6. 6.ID: 311028939
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
7. 7.ID: 310953457
While instructing a male client's wife in the performance of passive rangeofmotion 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?
A. Acknowledge that she is supporting the arm correctly. Correct
B. Encourage her to keep the joint covered to maintain warmth.
C. Reinforce the need to grip directly under the joint for better support.
D. Instruct her to grip directly over the joint for better motion.
8. 8.ID: 310978673
What is the most important reason for starting intravenous infusions in the upper extremities rather
than the lower extremities of adults?
A. It is more difficult to find a superficial vein in the feet and ankles.
B. A decreased flow rate could result in the formation of a
thrombosis. Correct
C. A cannulated extremity is more difficult to move when the leg or foot is
used.
D. Veins are located deep in the feet and ankles, resulting in a more painful
procedure.
9. 9.ID: 310949430
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?
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. Correct
C. Have the unit educator review this procedure with the UAPs.
D. Teach the UAP the correct technique for assessing blood pressure.
10. 10.ID: 310951961
A client is receiving a secondary infusion of a 300 mg dose medication q6 hour. The preparation
arrives from the pharmacy diluted in 50 mL of 0.9% Sodium Chloride (NaCl). The nurse plans to
administer the dose over 20 minutes. For how many mL/hour should the nurse program the infusion
pump to deliver the secondary infusion? (Enter the numeric value only.)
Correct Responses: "150"
11. 11.ID: 310965943
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.
D. The body's receptors adapt over time as they are exposed to
heat. Correct
12. 12.ID: 310955017
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. Correct
D. My blood level of low density lipoproteins needs to increase.
13. 13.ID: 310985659
The UAPs working on a chronic neuro unit ask the nurse to help them determine the safest way to
transfer an elderly client with leftsided weakness from the bed to the chair. What method describes
the correct transfer procedure for this client?
A. Place the chair at a right angle to the bed on the client's left side before
moving.
B. Assist the client to a standing position, then place the right hand on the
armrest.
C. Have the client place the left foot next to the chair and pivot to the left
before sitting.
D. Move the chair parallel to the right side of the bed, and stand the client
on the right foot. Correct
14. 14.ID: 310999015
An unlicensed assistive personnel (UAP) places a client in a left lateral position prior to administering
a soap suds enema. Which instruction should the nurse provide the UAP?
A. Position the client on the right side of the bed in reverse Trendelenburg.
B. Fill the enema container with 1000 ml of warm water and 5 ml of castile
soap.
C. Reposition in a Sim's position with the client's weight on the anterior
ilium. Correct
D. Raise the side rails on both sides of the bed and elevate the bed to
waist level.
15. 15.ID: 310949410
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. Correct
C. Alcohol use in any form is not allowed.
D. A vegetarian diet must be followed. [Show Less]