RN Fundamentals Online Practice 2023 A

Question:

A nurse is reviewing the laboratory results of a female client who has hypovolemia.Which of the following laboratory results would be a priority for the nurse to report to the provider?

A. BUN 21 mg/dL (10 to 20 mg/dL)B. Creatinine 1.4 mg/dL (0.5 to 1.1 mg/dL)C. Sodium 132 mEq/L (136 to 145 mEq/L)D. Potassium 5.8 mEq/L (3.5 to 5 mEq/L)

Correct Answer: D. Potassium 5.8 mEq/L (3.5–5 mEq/L)

Rationale:

A potassium level of 5.8 mEq/L indicates hyperkalemia, which is life-threatening and must be reported immediately.Clients with hypovolemia are at risk for decreased kidney perfusion, leading to impaired potassium excretion and elevated serum potassium.

Major risk:Hyperkalemia can cause fatal cardiac dysrhythmias, such as ventricular fibrillation or asystole.

A nurse has just inserted a nasogastric (NG) tube for a client.Which of the following findings should the nurse expect to confirm correct tube placement?

A. The tube aspirate has a pH of 7 (less than 5).B. An x-ray shows the end of the tube above the pylorus.C. Bowel sounds are present on auscultation.D. The client reports relief of nausea.

✅ Correct Answer: B. An x-ray shows the end of the tube above the pylorus.

Rationale:

The most accurate and reliable method to confirm correct NG tube placement is by x-ray visualization of the tube’s tip in the stomach, just above the pylorus.

This ensures that the tube is correctly placed and not in the lungs or esophagus, which can lead to aspiration or respiratory complications.

After confirming by x-ray, the nurse should document the tube length and external markings for future verification before feedings or medication administration.

A nurse is caring for a client who is receiving pain medication through a PCA pump.Which of the following actions should the nurse take?

A. Instruct the family to refrain from pushing the button for the client while the client is asleep.B. Inform the client that because they are on a PCA pump, vital signs will be taken every 8 hr.C. Teach the client to avoid pushing the button until pain is above a 7 on a scale of 0 to 10.D. Increase the basal rate and shorten the lock-out interval time if the client's pain level is too high.

✅ Correct Answer: A. Instruct the family to refrain from pushing the button for the client while the client is asleep.

Rationale:

Only the client should press the PCA (patient-controlled analgesia) button.This ensures that medication is administered based on the client’s level of pain and alertness.If a family member or nurse presses the button while the client is asleep, it can lead to over-sedation and respiratory depression, which can be life-threatening.

This is known as “PCA by proxy” and is strictly prohibited by safety protocols.

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?

A. Have the client wear a mask when receiving visitors.B. Wear a gown when caring for the client.C. Assign the client to a room with negative-pressure airflow exchange.D. Limit the client’s time with visitors to no more than 30 min per day.

✅ Correct Answer: B. Wear a gown when caring for the client.

Rationale:

Shigella is a bacterial infection transmitted by the fecal-oral route, often through contaminated food, water, or direct contact with stool.Clients with Shigella and diarrhea require contact precautions to prevent the spread of infection.

Contact precautions include:

Wearing gloves and a gown when entering the client’s room or providing care.

Using dedicated equipment (e.g., stethoscope, blood pressure cuff).

Performing thorough hand hygiene after removing gloves.

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?

A. Pad the client’s wrist before applying the restraints.B. Evaluate the client’s circulation every 8 hr after application.C. Remove the restraints every 4 hr to evaluate the client’s status.D. Secure the restraint ties to the bed’s side rails.

✅ Correct Answer: A. Pad the client’s wrist before applying the restraints.

Rationale:

Before applying wrist restraints, the nurse should pad the bony prominences (such as the wrists) to prevent skin injury, pressure ulcers, and impaired circulation.

This step ensures comfort and safety, and it’s part of proper restraint protocol.

A nurse is caring for a client who has limited mobility in their 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. Have the client use a trapeze bar when changing position.C. Massage areas of skin that are darker than the surrounding skin tissue with unscented lotion.D. Increase the client’s intake of carbohydrates.

✅ Correct Answer: B. Have the client use a trapeze bar when changing position.

Rationale:

Using a trapeze bar allows the client to lift themselves and reposition independently, which:

Reduces pressure on bony prominences,

Improves circulation, and

Prevents skin breakdown caused by friction or shear forces.

This intervention promotes mobility, independence, and skin integrity — key components of pressure injury prevention.

A nurse is caring for a client who has limited mobility in their 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. Have the client use a trapeze bar when changing position.C. Massage areas of skin that are darker than the surrounding skin tissue with unscented lotion.D. Increase the client’s intake of carbohydrates.

✅ Correct Answer: B. Have the client use a trapeze bar when changing position.

Rationale:

Using a trapeze bar allows the client to lift their body and reposition independently, reducing:

Pressure on bony prominences (such as the sacrum and heels),

Friction and shear, and

Risk of skin breakdown caused by immobility.

This also promotes independence, circulation, and comfort — key principles of pressure injury prevention.

A nurse is caring for a client who is having difficulty breathing.The client is supine and is receiving supplemental oxygen via a nasal cannula.Which of the following interventions should the nurse take first?

A. Suction the client’s airway.B. Instruct the client to perform incentive spirometry every hour.C. Humidify the client’s supplemental oxygen.D. Assist the client to an upright position.

✅ Correct Answer: D. Assist the client to an upright position.

Rationale:

This question is based on the ABC priority framework (Airway, Breathing, Circulation).When a client is having difficulty breathing, the first action should be to improve lung expansion and promote oxygen exchange.

Raising the head of the bed or assisting the client into an upright (Fowler’s) position helps:

Decrease pressure on the diaphragm,

Increase chest expansion, and

Improve ventilation and oxygenation.

This simple, noninvasive intervention often relieves dyspnea immediately and should be done before more invasive measures like suctioning.

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.

✅ Correct Answer: C. Subtract the amount of irrigant used from the client’s urine output.

Rationale:

When performing open catheter irrigation, the nurse introduces sterile solution into the catheter to maintain patency or remove blockage.Because this fluid does not represent true urine output, the nurse must:

➡️ Subtract the total amount of irrigation fluid used from the total measured output to determine the accurate urine volume.

This ensures precise intake and output (I&O) documentation, which is essential for assessing renal function and fluid balance.

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 indicating an injection."

✅ Correct Answer: A. "Use the complete name of the medication magnesium sulfate."

Rationale:

When documenting or prescribing medications, nurses must follow The Joint Commission’s “Do Not Use” abbreviation list to prevent medication errors and ensure patient safety.

The correct documentation practice is to write out the full medication name — for example:

✅ “magnesium sulfate”

❌ “MgSO₄”

Abbreviating can cause confusion with other medications (e.g., MgSO₄ vs. morphine sulfate).

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. Stand close to the cabinet when lifting it.C. Use the back muscles for lifting.D. Keep the feet close together.

✅ Correct Answer: B. Stand close to the cabinet when lifting it.

Rationale:

When lifting or moving objects, nurses should follow proper body mechanics to prevent musculoskeletal injuries.Standing close to the object keeps the load near the body’s center of gravity, which:

Reduces strain on the back and arms,

Improves balance and stability, and

Decreases the risk of back injury.

Other key principles include:

Bend at the knees, not at the waist.

Use leg muscles, not back muscles.

Keep feet shoulder-width apart for balance.

A nurse is caring for a client with a diagnosis of terminal cancer.Which of the following statements by the client should indicate to the nurse that the client is ready to hear information regarding palliative care?

A. "I am ready to learn about chemotherapy to help cure my cancer."B. "I just want you to give me something to get this over with soon."C. "I know that many people have recovered fully from cancer, and so will I."D. "I want you to tell me about measures available to keep me comfortable."

✅ Correct Answer: D. "I want you to tell me about measures available to keep me comfortable."

Rationale:

This statement shows that the client:

Accepts their terminal diagnosis, and

Is open to discussing comfort-focused care, which is the main goal of palliative care.

Palliative care focuses on:

Relieving pain and symptoms,

Improving quality of life, and

Providing emotional and spiritual support, rather than attempting to cure the disease.

This statement indicates the client is ready to discuss end-of-life comfort measures and non-curative interventions.

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.(Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Steps:

Place a name tag on the body.

Obtain the pronouncement of death from the provider.

Remove tubes and indwelling lines.

Wash the client’s body.

Ask the client’s family members if they would like to view the body

✅ Correct Order of Steps:

1️⃣ Obtain the pronouncement of death from the provider.2️⃣ Remove tubes and indwelling lines.3️⃣ Wash the client’s body.4️⃣ Place a name tag on the body.5️⃣ Ask the client’s family members if they would like to view the body.

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 they received about pain management?

A. "I think I should take my pain medication more often, since it is not controlling my pain."B. "Breathing faster will help me keep my mind off of the pain."C. "It might help me to listen to music while I'm lying in bed."D. "I don't want to walk today because I have some pain."

✅ Correct Answer: C. "It might help me to listen to music while I'm lying in bed."

Rationale:

This statement shows the client understands nonpharmacological pain management techniques, such as distraction or relaxation strategies (e.g., listening to music).Using complementary methods along with prescribed pain medication helps manage discomfort and promotes recovery.

Listening to music can:

Distract attention from pain,

Lower anxiety,

Promote relaxation, and

Enhance overall comfort postoperatively.

A nurse is completing an admission assessment for a client who reports vomiting and diarrhea for the past 3 days.Which of the following findings should the nurse expect?

A. Neck vein distentionB. Urine specific gravity 0.99 (1.01 to 1.025)C. Rapid heart rateD. Blood pressure 144/82 mm Hg

✅ Correct Answer: C. Rapid heart rate

Rationale:

Vomiting and diarrhea for several days cause fluid volume deficit (dehydration).The body compensates for decreased circulating volume by increasing heart rate (tachycardia) to maintain cardiac output.

Expected Findings in Fluid Volume Deficit (Hypovolemia):

↑ Heart rate (tachycardia) — compensatory mechanism

↓ Blood pressure (hypotension or orthostatic hypotension)

↓ Skin turgor, dry mucous membranes

↑ Urine specific gravity (>1.025) — concentrated urine

↓ Urine output

Flat neck veins (not distended)

Cool, clammy skin

A nurse is preparing to delegate client care tasks to an assistive personnel (AP).Which of the following tasks should the nurse delegate?

A. Ambulating a client who is postoperativeB. Inserting an indwelling urinary catheter for a clientC. Demonstrating the use of an incentive spirometer to a clientD. Confirming that a client’s pain has decreased after receiving an analgesic

✅ Correct Answer: A. Ambulating a client who is postoperative

Rationale:

Assistive personnel (APs) can safely perform tasks that are routine, have predictable outcomes, and do not require nursing judgment or assessment.Ambulating a stable postoperative client falls under this category, as long as the client has been cleared for ambulation and the nurse has first assessed for stability and safety.

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?

A. The client uses a wool blanket on their bed.B. The client identifies the location of a fire extinguisher.C. The client stores an extra oxygen tank on its side under their bed.D. The client has a weekly inspection checklist for oxygen equipment.

✅ Correct Answer: B. The client identifies the location of a fire extinguisher.

Rationale:

Knowing the location of a fire extinguisher is a critical home safety measure for clients using supplemental oxygen.Oxygen supports combustion, so being prepared for potential fires and knowing how to respond is part of oxygen therapy safety protocol.

A nurse is caring for a client who is postoperative. When the nurse prepares to change the client’s dressing, they say,

“Every time you change my bandage, it hurts so much.”Which of the following interventions is the nurse’s priority action?

A. Encourage the client to relax and take deep breaths during the dressing change.B. Educate the client about the importance of the dressing change to prevent infection.C. Assist the client to a comfortable position for the dressing change.D. Administer pain medication 45 min before changing the client’s dressing.

✅ Correct Answer: D. Administer pain medication 45 min before changing the client’s dressing.

Rationale:

This question tests Maslow’s Hierarchy of Needs and the Nursing Process (ADPIE — Assessment, Diagnosis, Planning, Implementation, Evaluation).The priority is to address physiologic needs — in this case, pain management — before performing procedures or providing education.

Administering pain medication prior to a painful procedure (30–45 min before) allows time for it to take effect, ensuring comfort and reducing stress during the dressing change.

Once pain is managed, the nurse can then assist with positioning and provide teaching.

A nurse in a surgical suite notes documentation on a client’s medical record that they have 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.

✅ Correct Answer: B. Wrap monitoring cords with stockinette and tape them in place.

Rationale:

Clients with a latex allergy must be protected from any contact with latex-containing materials. Many hospital supplies (e.g., blood pressure cuffs, catheters, monitoring cords) contain latex components.Wrapping these items in stockinette (soft, non-latex covering) and taping them ensures that the client’s skin does not come into direct contact with latex surfaces.

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

A. Verify the client’s name on their identification bracelet with the medication administration record.B. Call the pharmacy to determine whether the client’s medications are available.C. Compare the client’s home medications with the provider’s prescriptions.D. Place the client’s home medication bottles in a secure location.

✅ Correct Answer: C. Compare the client’s home medications with the provider’s prescriptions.

Rationale:

Medication reconciliation is the process of comparing the medications a client has been taking (at home or another facility) with the newly prescribed medications upon admission, transfer, or discharge.

The goal is to identify and resolve discrepancies such as:

Omissions (missed medications)

Duplications

Dosing errors

Drug interactions

By comparing home medications to provider prescriptions, the nurse ensures continuity of care and prevents medication errors.

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 minutes and to report back in 1 hour. Which of the following actions should the nurse take next?

A. Document the provider’s statement in the medical record.B. Complete an incident report.C. Consult the facility’s risk manager.D. Notify the nursing manager.

✅ Correct Answer: D. Notify the nursing manager.

Rationale:

The provider’s order to “measure vital signs every 15 minutes and report back in 1 hour” is inappropriate and unsafe for a client exhibiting signs of hemorrhagic shock.Hemorrhagic shock is a life-threatening emergency requiring immediate intervention, such as:

Rapid fluid replacement (IV fluids, blood products)

Oxygen therapy

Preparing for possible surgical intervention

If the provider gives a negligent or unsafe order, the nurse has a duty to advocate for the client’s safety by following the chain of command—that means notifying the nursing manager (charge nurse or supervisor) immediately.

A nurse is discussing the use of herbal supplements for health promotion with a client. Which of the following client statements indicates an understanding of herbal supplement use?

A. "I can take echinacea to improve my immune system."B. "I can take feverfew to reduce my level of anxiety."C. "I can take ginger to improve my memory."D. "I can take ginkgo biloba to relieve nausea."

✅ Correct Answer: A. "I can take echinacea to improve my immune system."

Rationale:

Echinacea is an herbal supplement commonly used to stimulate the immune system and help prevent or reduce the duration of upper respiratory infections (like the common cold).

It may cause allergic reactions in clients allergic to ragweed, daisies, or chrysanthemums.

It should not be used long-term because prolonged use can decrease immune response.

A nurse is caring for a client who is scheduled to be transferred to a long-term care facility. The client’s family questions the nurse about the reasons for the transfer. Which of the following responses made by the nurse is appropriate?

A. "The transfer of your family member is being done because the provider knows what's best."B. "Would you like it if we discussed the transfer with your family member?"C. "Why are you so concerned about this transfer?"D. "I know how you feel. My parent had to be transferred to a long-term care facility."

✅ Correct Answer: B. "Would you like it if we discussed the transfer with your family member?"

Rationale:

Option B demonstrates therapeutic communication.

It invites the family to participate in the discussion, shows respect for their feelings, and promotes open communication and client-centered care.

It helps maintain trust and encourages involvement in decision-making.

A nurse enters a client’s room and finds them on the floor. The client’s roommate reports that the client was trying to get out of bed and fell over the side rail onto the floor. Which of the following statements should the nurse document about this incident?

A. "Incident report completed."B. "Client climbed over the side rails."C. "Client found lying on floor."D. "Client was trying to get out of bed."

✅ Correct Answer: C. "Client found lying on floor."

Rationale:

Option C is the only statement that is objective, factual, and observable — which is the correct method of documentation.

It simply states what the nurse directly observed without including opinions, assumptions, or secondhand information.

Nursing documentation should always reflect objective facts and avoid subjective interpretations or blame.

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?

A. AlginateB. GauzeC. TransparentD. Hydrocolloid

✅ Correct Answer: D. Hydrocolloid

Rationale:

Stage 2 pressure injuries involve partial-thickness skin loss with exposure of the dermis.

The wound is usually pink or red, moist, and may appear as a blister or shallow crater.

The main goal of treatment is to maintain a moist wound environment and protect the wound from friction and contamination.

Hydrocolloid dressings are ideal because they:

Form a gel-like barrier that keeps the wound moist.

Promote autolytic debridement (the body’s natural cleaning of dead tissue).

Provide protection against bacteria and friction.

Can be left in place for 3–7 days, reducing trauma to the wound.

A nurse is caring for a client who requires a 24-hour 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."

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

Rationale:

The correct procedure for a 24-hour urine collection begins by discarding (flushing) the first voided specimen.

This ensures that the bladder is empty and the collection starts with fresh urine.

From that time forward, all urine must be saved for the next 24 hours, including the final void at the end of the period.

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?

A. Make sure the client's room has at least six air exchanges per hour.B. Make sure the client wears a mask when outside their room if there is construction in the area.C. Place the client in a private room with negative-pressure airflow.D. Wear an N95 respirator when giving the client direct care.

✅ Correct Answer: B. Make sure the client wears a mask when outside their room if there is construction in the area.

Rationale:

Clients who have undergone allogeneic stem cell transplantation are severely immunocompromised and require a protective environment to prevent infection from airborne and environmental pathogens.

If there is construction nearby, fungal spores such as Aspergillus can circulate in the air — posing a serious infection risk to immunocompromised clients.Therefore, the client must wear a mask whenever leaving their room during construction or maintenance activities.

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 airflow 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.

✅ Correct Answer: D. Have family members wear a gown and gloves when visiting.

Rationale:

Clients who have Clostridium difficile (C. diff) require contact precautions to prevent transmission through direct contact or indirect contact with contaminated surfaces or equipment.

Visitors and healthcare workers must wear gloves and gowns when entering the client’s room to reduce the spread of spores. C. diff spores can survive on surfaces for long periods and are resistant to many disinfectants.

A middle adult client tells the nurse, “I feel so useless now that my children do not need me anymore.”Which of the following responses should the nurse make?

A. “Most people are happy when their children grow up and leave home.”B. “You should be proud that your children are becoming independent.”C. “Maybe you should consider why you are feeling useless.”D. “People in middle adulthood often find satisfaction in nurturing and guiding young people.”

✅ Correct Answer: D. “People in middle adulthood often find satisfaction in nurturing and guiding young people.”

Rationale:

This question relates to Erikson’s psychosocial stage of development — specifically, the generativity vs. stagnation stage, which occurs during middle adulthood (ages 40–65).

During this stage, individuals strive to contribute to the next generation through nurturing, mentoring, teaching, or community involvement.

A sense of uselessness or lack of productivity may indicate role confusion or stagnation.

The nurse’s role is to help the client redirect focus toward finding meaning in guiding and supporting others, such as volunteering, mentoring youth, or engaging in creative work.

Therefore, option D is the most therapeutic and developmentally supportive response.

A nurse is admitting a client who has rubella. Which of the following types of transmission-based precautions should the nurse initiate?

A. DropletB. AirborneC. ContactD. Protective environment

✅ Correct Answer: A. Droplet

Rationale:

Rubella (also known as German measles) is spread primarily through droplet transmission. The virus is transmitted via large respiratory droplets that are produced when an infected person coughs, sneezes, or talks.

Therefore, droplet precautions must be implemented to prevent transmission to others.

A nurse is preparing to administer 0.9% sodium chloride 750 mL IV to infuse over 7 hr.How many mL/hr should the nurse set the infusion pump to deliver?

107 mL/hr

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?

Options:

Protective environment

Airborne precautions

Droplet precautions

Contact precautions

✅ Correct Answer:

4. Contact precautions

Rationale:

Purulent drainage indicates infection with microorganisms that can spread by direct contact with the wound or contaminated surfaces.

Therefore, contact precautions are necessary to prevent transmission.

Nursing actions under contact precautions:

Wear gloves and a gown when touching the client or the client’s environment.

Dedicate patient care equipment (e.g., stethoscope, blood pressure cuff).

Perform hand hygiene before and after removing gloves.

Use a private room or cohort clients with the same infection.

Protective environment → Used for immunocompromised clients (e.g., transplant).Airborne precautions → Used for tuberculosis, measles, varicella.Droplet precautions → Used for influenza, meningitis, pertussis.

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 assistive personnel (AP)?(Select all that apply.)

Options:

Assist the client with a partial bed bath.

Measure the client’s BP after the nurse administers an antihypertensive medication.

Test the client’s swallowing ability by providing thickened liquids.

Use a communication board to ask what the client wants for lunch.

Irrigate the client’s indwelling urinary catheter.

✅ Correct Answers:

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.

Rationales:

(1) Partial bed bath:This is a routine hygiene task that falls within the scope of an assistive personnel (AP).

(2) Measure BP after medication:Monitoring vital signs after medication administration is appropriate for an AP, as long as the nurse interprets the results.

(4) Use communication board:Assisting the client with basic communication needs is appropriate for an AP, especially for a client with aphasia.

A nurse is assessing a client's readiness to learn about insulin self-administration.Which of the following statements should the nurse identify as an indication that the client is ready to learn?

Options:

"I can concentrate best in the morning."

"It is difficult to read the instructions because my glasses are at home."

"I'm wondering why I need to learn this."

"You will have to talk to my partner about this."

✅ Correct Answer:

1. "I can concentrate best in the morning."

Rationale:

This statement shows that the client is motivated and prepared to participate in learning by identifying the best time to focus and absorb new information.➤ This indicates readiness to learn, an important part of the teaching process.

A nurse is planning an educational program for a group of older adults at a senior living center.Which of the following recommendations should the nurse include?

Options:

"You should have an eye examination every 2 years."

"You should receive a tetanus booster every 5 years."

"You should receive a shingles vaccine when you are 70 years old."

"You should receive a pneumococcal vaccine when you are 65 years old."

✅ Correct Answer:

4. "You should receive a pneumococcal vaccine when you are 65 years old."

Rationale:

Pneumococcal vaccine is recommended for all adults 65 years and older to protect against Streptococcus pneumoniae, which can cause pneumonia, meningitis, and bloodstream infections.➤ CDC recommends one dose of PPSV23 (Pneumovax 23) or PCV20 depending on vaccination history.

A nurse is caring for a client who has tuberculosis.Which of the following actions should the nurse take? (Select all that apply.)

Options:

Place the client in a room with negative-pressure airflow.

Wear gloves when assisting the client with oral care.

Limit each visitor to 2-hr increments.

Wear a surgical mask when providing client care.

Use antimicrobial sanitizer for hand hygiene.

✅ Correct Answers:

1. Place the client in a room with negative-pressure airflow.2. Wear gloves when assisting the client with oral care.

Rationale:

1️⃣ Negative-pressure room:TB is an airborne infection, meaning it spreads through tiny droplet nuclei.Clients with active TB must be placed in a negative-pressure isolation room to prevent contaminated air from escaping into other areas.Air should be filtered through a HEPA filtration system before recirculating.

2️⃣ Wear gloves during oral care:Standard precautions apply — gloves must be worn for contact with mucous membranes or body fluids.

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?

Options:

"Is your pain constant or intermittent?"

"What would you rate your pain on a scale of 0 to 10?"

"Does the pain radiate?"

"Is your pain sharp or dull?"

✅ Correct Answer:"Is your pain sharp or dull?"

Rationale:Asking if the pain is sharp or dull assesses the quality of pain, describing its characteristics or sensation type. The other options assess intensity, pattern, or location.

A nurse is caring for a client who has a nasogastric (NG) tube and is receiving intermittent feedings through an open system.Which of the following actions should the nurse take first?

Options:

Rinse the feeding bag with water between feedings.

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

Make sure the enteral formula is at room temperature.

Wipe the top of the formula can with alcohol.

✅ Correct Answer:

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

Rationale:

1️⃣ Airway safety comes first (ABCs):The highest priority when administering enteral feedings is to prevent aspiration.Keeping the head of the bed elevated at least 30° to 45° reduces the risk of regurgitation and aspiration of gastric contents into the lungs.

2️⃣ Other actions are important but secondary:

Rinse the feeding bag with water between feedings:Prevents bacterial growth and clogging, but not as urgent as protecting the airway.

Make sure the enteral formula is at room temperature:Prevents abdominal cramping, but it’s a comfort measure—not a safety priority.

Wipe the top of the formula can with alcohol:Prevents contamination but should be done after ensuring airway protection.

🩺 Priority Framework:

Use the ABC (Airway, Breathing, Circulation) and Maslow’s Hierarchy of Needs frameworks — airway and safety always come first.

A nurse is caring for a client who has an indwelling urinary catheter.Which of the following findings indicates that the catheter requires irrigation?

Options:

Urine has an unusual odor.

Urine specific gravity is 1.035 (1.01 to 1.025).

Bladder scan shows 525 mL of urine.

Urine is positive for ketones.

✅ Correct Answer:

✔ Bladder scan shows 525 mL of urine.

Rationale:

1️⃣ Retention with catheter in place:If a bladder scan shows a large volume of retained urine (e.g., >300–500 mL), it means urine is not draining properly through the catheter — most likely due to an obstruction or blockage.The nurse should irrigate the catheter to restore patency and allow urine flow.

2️⃣ Other findings explained:

Urine has an unusual odor:This could indicate a urinary tract infection (UTI), not the need for irrigation. Irrigation would not treat odor or infection.

Urine specific gravity 1.035:Indicates concentrated urine or dehydration, not a catheter blockage.

Urine positive for ketones:Suggests fat metabolism (common in starvation, fasting, or diabetic ketoacidosis), unrelated to catheter irrigation.

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?

Options:

Role ambiguity

Sick role

Role overload

Role conflict

✅ Correct Answer:

✔ Role overload

Rationale:

1️⃣ Role overload:This occurs when a person has too many responsibilities or demands within a given role and feels unable to fulfill all of them effectively.In this case, the client’s partner is struggling to balance caregiving duties and household responsibilities, leading to stress and frustration — classic signs of role overload.

2️⃣ Other options explained:

Role ambiguity:Happens when a person is uncertain about expectations or responsibilities within their role. The partner’s role is clear — they’re just overwhelmed by the workload.

Sick role:Refers to behaviors and expectations of someone who is ill, not the caregiver.

Role conflict:Occurs when a person faces competing demands between two different roles (e.g., being a parent and an employee).In this case, the partner’s issue stems from too many demands within the same caregiving role, not conflicting ones.

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?

Options:

Ask the client to consider a direct donation.

Withhold the blood transfusion.

Request a consultation with the ethics committee.

Ask the client’s family to intervene.

✅ Correct Answer:

✔ Withhold the blood transfusion

Rationale:

1️⃣ Autonomy and informed consent:Every competent adult has the legal and ethical right to refuse treatment, even if the decision could lead to death.The nurse must respect the client’s autonomy and their religious beliefs, regardless of the wishes of family members or providers.

2️⃣ Informed refusal:As long as the client has been fully informed of the consequences of refusing treatment (e.g., potential death) and is competent to make their own decision, the nurse must honor that refusal.

3️⃣ Religious considerations:This is commonly seen among Jehovah’s Witnesses, who refuse blood products based on religious doctrine.Alternative treatments may be discussed (such as volume expanders or erythropoietin), but forced transfusion violates ethical and legal principles.

A nurse is planning care of an adolescent who is postoperative following a lumbar laminectomy.Which of the following interventions should the nurse include in the plan of care?

Options:

Limit the adolescent’s visitors.

Select the food choices for the adolescent.

Allow the adolescent to make decisions regarding their daily routine.

Encourage the adolescent’s guardian to assist with personal hygiene.

✅ Correct Answer:

✔ Allow the adolescent to make decisions regarding their daily routine.

Rationale:

1️⃣ Promoting autonomy and independence:Adolescents are in Erikson’s stage of Identity vs. Role Confusion, where they are developing independence and self-identity.Allowing them to make decisions (such as what time to bathe, which clothes to wear, or what activities to do first) supports this developmental need and fosters a sense of control during hospitalization.

2️⃣ Encourages cooperation and trust:When adolescents are given choices, they feel respected and are more likely to engage in their care and adhere to the treatment plan.

3️⃣ Supports emotional well-being:Loss of control during hospitalization can cause anxiety or rebellion in teens. Providing age-appropriate decision-making opportunities helps maintain self-esteem and emotional stability.

A nurse is admitting a client who has been having frequent tonic-clonic seizures.Which of the following actions should the nurse add to the client’s plan of care?

Options:

Wrap blankets around all four sides of the bed.

Apply restraints during seizure activity.

Place the client in a supine position during seizure activity.

Have a tongue depressor at the client’s bedside.

✅ Correct Answer:

✔ Wrap blankets around all four sides of the bed.

Rationale:

1️⃣ Seizure precautions:The priority for a client with frequent tonic-clonic (grand mal) seizures is injury prevention.Padding or wrapping blankets around bed rails prevents head or limb trauma if the client strikes the side of the bed during a seizure.

2️⃣ Maintain safety, not restriction:The nurse should keep the environment safe, ensure oxygen and suction equipment are available, and turn the client to their side during a seizure to maintain airway patency and prevent aspiration.

A nurse is caring for a client who has a sodium level of 125 mEq/L (normal range: 136 – 145 mEq/L).Which of the following findings should the nurse expect?

Options:

Numbness of the extremities

Bradycardia

Positive Chvostek’s sign

Abdominal cramping

✅ Correct Answer:

✔ Abdominal cramping

Rationale:

1️⃣ Hyponatremia (Na⁺ < 136 mEq/L):This electrolyte imbalance leads to cellular swelling due to a shift of water into cells.Low sodium affects neuromuscular and gastrointestinal (GI) function.

Expected findings include:

Abdominal cramping

Nausea and vomiting

Headache, confusion, or seizures (if severe)

Muscle weakness or fatigue

GI hypermotility is common because low sodium alters smooth muscle excitability, causing abdominal discomfort and cramping.

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

Options:

Use the Face, Legs, Activity, Cry, and Consolability (FLACC) pain rating scale for a client who is experiencing pain.

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

Obtain an apical heart rate by auscultating at the third intercostal space left of the sternum.

Palpate the client’s abdomen before auscultating bowel sounds.

✅ Correct Answer:

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

Rationale:

1️⃣ Blood Pressure Cuff Accuracy:The width of the cuff’s bladder should cover 40% of the arm circumference, and the length should cover 80% of the arm’s circumference.This ensures an accurate blood pressure reading.If the cuff is too small → falsely high reading.If too large → falsely low reading.

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

Options:

Increase in hematocrit

Increase in respiratory rate

Decrease in heart rate

Decrease in capillary refill time

✅ Correct Answer:

✔ Decrease in heart rate

Rationale:

1️⃣ Fluid Volume Deficit (Hypovolemia):When a client is dehydrated or hypovolemic, there’s less circulating blood volume.To compensate, the body increases the heart rate (tachycardia) to maintain cardiac output and tissue perfusion.

After receiving IV fluids (like 0.9% sodium chloride, an isotonic solution), circulating volume increases, perfusion improves, and the heart rate returns to normal.→ Therefore, a decrease in heart rate is the best indication that treatment was effective.

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

Options:

Increase in hematocrit

Increase in respiratory rate

Decrease in heart rate

Decrease in capillary refill time

✅ Correct Answer:

✔ Evacuate the client.

Rationale:

This question is based on the RACE protocol for fire safety:

🔥 R — Rescue🧯 A — Alarm🚪 C — Contain💦 E — Extinguish/Evacuate

1️⃣ Rescue (Evacuate the client):The nurse’s first priority is to rescue any clients in immediate danger, especially those who cannot ambulate (like in this question).The nurse should move the client to safety before doing anything else.

2️⃣ Alarm (Activate the fire alarm):After rescuing the client(s), the nurse should activate the alarm to alert others and initiate the facility’s emergency response system.

3️⃣ Contain (Close doors/windows):Once clients are safe and the alarm is activated, close doors to help contain the fire and prevent its spread.

4️⃣ Extinguish (Only if safe):The nurse should attempt to extinguish the fire only if it is small and manageable, and if the nurse has a clear exit route.

A client who is nonambulatory notifies the nurse that their trash can is on fire.After the nurse confirms the presence of the fire, which of the following actions should the nurse take next?

Options:

Activate the emergency fire alarm.

Extinguish the fire.

Evacuate the client.

Confine the fire.

✅ Correct Answer:

✔ Evacuate the client.

Rationale:

The nurse should follow the RACE protocol for fire emergencies:

R — RescueA — AlarmC — ContainE — Extinguish/Evacuate

1️⃣ Rescue (Evacuate the client):The first priority is to remove anyone in immediate danger, especially clients who cannot ambulate (nonambulatory).The nurse should move the client to safety before taking any other action.

2️⃣ Alarm (Activate the emergency alarm):Once all clients in danger are safe, activate the alarm system to alert the rest of the facility and fire department.

3️⃣ Contain (Close doors and windows):After the alarm is activated, close all doors and windows to prevent the spread of smoke and flames.

4️⃣ Extinguish (If possible):If the fire is small and manageable, and the nurse has a clear exit route, they may use a fire extinguisher to put it out.

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?

Options:

During the admission process

As soon as the client’s condition is stable

During the initial team conference

After consulting with the client’s family

✅ Correct Answer:

✔ During the admission process

Rationale:

1️⃣ Discharge planning begins at admission.The nurse should initiate discharge planning as soon as the client is admitted to the facility.This allows the healthcare team to identify potential barriers, assess support systems, and plan for continuity of care early — ensuring a safe transition from hospital to home or another care setting.

2️⃣ Early planning improves outcomes.Early discharge planning helps:

Prevent readmissions (especially in chronic conditions like heart failure).

Coordinate home health referrals, equipment, and medications.

Educate the client and family about necessary lifestyle changes, medication adherence, and follow-up appointments.

A nurse is caring for a client who reports difficulty falling asleep.Which of the following recommendations should the nurse make?

Options:

Drink a cup of hot cocoa before bedtime.

Maintain a consistent time to wake up each day.

Exercise 1 hour before going to bed.

Watch a television program in bed before going to sleep.

✅ Correct Answer:

✔ 2. Maintain a consistent time to wake up each day.

Rationale:

1️⃣ Consistent wake-up time promotes a healthy sleep-wake cycle.Encouraging the client to wake up at the same time every day helps regulate the body’s circadian rhythm (internal clock).This consistency improves overall sleep quality and makes it easier to fall asleep at night.

2️⃣ Good sleep hygiene includes:

Going to bed and waking up at the same times each day.

Avoiding caffeine, nicotine, or alcohol before bedtime.

Keeping the bedroom dark, quiet, and cool.

Limiting screen time or stimulating activities before bed.

Using the bed only for sleep and intimacy.

A nurse is planning care for a client who has vision loss.Which of the following interventions should the nurse include in the plan of care to assist the client with feeding?

Options:

Assign a staff member to feed the client.

Provide small-handled utensils for the client.

Thicken liquids on the client’s tray.

Arrange food in a consistent pattern on the client’s plate.

✅ Correct Answer:

✔ 4. Arrange food in a consistent pattern on the client’s plate.

Rationale:

1️⃣ Consistent plate arrangement promotes independence.Clients with vision loss can feed themselves if their food is arranged in a predictable, consistent pattern (e.g., describing food by the face of a clock: “Your chicken is at 6 o’clock, your potatoes are at 3 o’clock”).This enhances orientation, safety, and independence during meals.

2️⃣ The goal is to encourage self-feeding, not dependence.Assigning a staff member to feed the client limits autonomy and should only be done if the client physically cannot self-feed.

3️⃣ Thickened liquids are for clients with dysphagia (swallowing difficulty), not for those with vision loss.

4️⃣ Special utensils (e.g., small-handled) are useful for clients with limited motor control, such as Parkinson’s disease, but not specifically for vision loss.

A nurse is caring for a client who has a terminal diagnosis and whose health is declining.The client requests information about advance directives.Which of the following responses should the nurse make?

Options:

"We can talk about advance directives, and I can also give you some brochures about them."

"You should set up a time to talk with your provider about that."

"Let's discuss how you are feeling today, and we'll save the planning for when you are feeling a little better."

"Why do you want to discuss this without your partner here to plan this with you?"

✅ Correct Answer:

✔ 1. "We can talk about advance directives, and I can also give you some brochures about them."

Rationale:

1️⃣ Client autonomy and education:The nurse’s role is to provide information and support when a client expresses interest in advance directives.This response demonstrates openness, respect for the client’s autonomy, and provision of resources for informed decision-making.

2️⃣ Provider referral is not necessary — the nurse is qualified to provide information and resources about advance directives and can help initiate the conversation.

3️⃣ Postponing the discussion dismisses the client’s request and fails to support timely end-of-life planning, which is inappropriate and non-therapeutic.

4️⃣ Questioning the client’s motives (“Why do you want to…?”) is non-therapeutic and judgmental, potentially making the client defensive or uncomfortable.

A nurse is assessing a client who received an IV fluid bolus for dehydration.Which of the following findings should the nurse identify as an indication of fluid volume excess?

Options:

Hypotension

Weak, thready pulse

Slow capillary refill

Distended neck veins

✅ Correct Answer:

✔ 4. Distended neck veins

Rationale:

1️⃣ Fluid volume excess (FVE):Occurs when too much fluid accumulates in the intravascular space.Key clinical manifestations include:

Distended neck veins (JVD) due to increased venous pressure

Bounding pulse

Hypertension

Crackles in the lungs / pulmonary congestion

Peripheral edema

Weight gain

Distended neck veins reflect elevated central venous pressure (CVP), a hallmark of fluid overload.

2️⃣ Hypotension and 3️⃣ weak, thready pulse indicate fluid volume deficit — signs of hypovolemia, not excess.

4️⃣ Slow capillary refill also points to dehydration or poor perfusion, not overload.