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Fundamentals Practice Test B with NGN

Terms in this set (60)

A nurse is providing discharge teaching for a client who has a new prescription for a home oxygen concentrator. Which of the following instructions should the nurse provide to the client and his family? (Select all that apply.)
- Check the cord routinely for frays or tearing.
- Consider purchasing a generator for power backup.
- Observe for signs of hypoxia.
A charge nurse is observing a newly licensed nurse prepare a sterile field for a dressing change. Which of the following actions by the newly licensed nurse requires intervention by the charge nurse?
The newly licensed nurse places the cap of a bottle of sterile saline solution on the sterile field.
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?
Have family members wear a gown and gloves when visiting.
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?
Walking briskly
A nurse is preparing to delegate client care tasks to an assistive personnel (AP). Which of the following tasks should the nurse delegate?
Ambulating a client who is postoperative
A nurse is preparing a heparin infusion for a client who was admitted to the facility with deep-vein thrombosis. The prescription reads: 25,000 units of heparin in 0.9% sodium chloride 250 mL 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 community health nurse is checking blood pressures for a group of clients at a community health screening. Which of the following clients is at an increased risk for hypertension?
A client who smokes one pack of cigarettes each day
A nurse is reviewing a client's medication prescription that reads, "digoxin 0.25 by mouth every day." Which of the following components of the prescription should the nurse verify with the provider?
Medication dose
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?
Select a suction catheter that is half the size of the lumen.
A nurse is caring for a group of clients on a medical-surgical unit. In which of the following situations does the nurse demonstrate the ethical principle of veracity?
A client who is unaware of her recent cancer diagnosis asks the nurse if she has cancer, and the nurse responds affirmatively.
Based on the client's clinical findings, which of the following actions should the nurse take? Select all that apply.

A nurse in the emergency department (ED) is caring for a client who reports abdominal pain.

Exhibit 1:
Nurses' Notes: 1200: Client arrives to ED and reports abdominal pain and no bowel movement for the past 7 days. Client is undergoing chemotherapy for pancreatic cancer and has been taking 40 mg oxycodone extended-release tablets daily for the past 3 months. Client states they have attempted to relieve constipation for the last 7 days with bisacodyl suppositories and magnesium citrate oral suspension. Client reports that neither therapy initiated defecation.

1230: Client transported for abdominal x-ray.

1245: Client returned from x-ray. Provider prescribes a hypertonic cleansing enema.

1300: Procedure explained to client who verbalized understanding.

Exhibit 2:
Diagnostic Results: 1245: Abdominal x-ray indicates a large amount of fecal material throughout the colon. No evidence of gastrointestinal obstruction observed.
- Assist the client to a left side-lying position with the right knee flexed.
- Administer a cleansing enema.
- Auscultate the client's bowel sounds.
- Perform a manual digital examination of the client's rectum.
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?
"What could I have done to deserve this illness?"
A nurse is preparing to transfer a client who can bear weight on one leg from the bed to a chair. After securing a safe environment, which of the following actions should the nurse take next?
Assess the client for orthostatic hypotension.
A nurse is giving change-of-shift report about a client they admitted earlier that day who has pneumonia. Which of the following pieces of information is the priority for the nurse to provide?
Breath sounds
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?
Initiate an enteral feeding through a gastrostomy tube.
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?
"I flushed what I urinated at 7:00 a.m. and have saved all urine since."
Click to highlight the findings that indicate the client is malnourished.

A nurse in the emergency department (ED) is caring for a client.

Exhibit 1:
Nurses' Notes: 1100: Client arrives to ED and reports nausea, vomiting, and diarrhea for 3 days. Client is febrile.

1110: Provider at bedside; prescriptions received.
1115: IV initiated to right arm with 20-gauge catheter. Acetaminophen and metoclopramide administered.
1200: Client appears fatigued, with no energy. Hair is thin and sparse. Cachectic, with flaccid muscle tone. Oriented x 3, able to move all extremities. Tachycardia, edema to lower extremities. Respirations unlabored, chest clear. Bowel sounds x 4 hyperactive, abdomen distended. Reports no difficulty with urination. Skin dry and scaly with bruises on extremities.

Exhibit 2:
MAR: 1115: Acetaminophen 650 mg rectal every 6 hr PRN temperature greater than 38.3° C (101° F), Metoclopramide 10 mg IV every 6 hr PRN nausea/vomiting

Exhibit 3:
Vital Signs: 1100:Temperature 39.2° C (102.6° F), Pulse rate 118/min, Respiratory rate 18/min, Blood pressure 92/68 mm Hg, Oxygen saturation 95%Weight 44.9 kg (99 lb)BMI 17
- Cachectic, with flaccid muscle tone.
- Skin dry and scaly with bruises on extremities.
- Pulse rate 118/min
- Abdomen distended
- BMI 17
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?
Rapid heart rate
A nurse is teaching a group of staff nurses about the use of essential oils for aromatherapy. The nurse should include in the teaching that this therapy might be contraindicated for which of the following clients?
A client who has asthma
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?
"You should receive a pneumococcal vaccine when you are 65 years old."
Click to highlight the findings that the nurse should report to the provider.

A nurse is caring for a client who has a pressure injury.

Exhibit 1:
Nurses' Notes: Day 1: Client is alert and oriented to person, place, and time. Client has stage 2 pressure injury on coccyx. Wound tissue is pink with no drainage. Lungs clear on auscultation. Heart sounds are regular. +2 peripheral pulses and no presence of edema in lower extremities. Bowel sounds active x 4 quadrants. Client ate 50% of breakfast. Client reports pain to pressure injury as 2 on a scale of 0 to 10. Client repositioned every 2 hr while in bed.

Day 4: Client has stage 2 pressure injury on coccyx. Wound tissue is yellow with purulent drainage. Wound has foul odor. Client ate 75% of breakfast. Client reports pain to pressure injury as 6 on a scale of 0 to 10. Client repositioned every 2 hr while in bed.

Exhibit 2:
Vital Signs: Day 4: Temperature 38.3° C (101° F), Pulse rate 80/min, Respiratory rate 20/min, Blood pressure 128/64 mm Hg, Oxygen saturation 93% on room air

Exhibit 3:
Diagnostic Results: Day 4: Potassium 4.2 mEq/L (3.5 to 5 mEq/L), Hgb 13 g/dL (12 to 16 g/dL), Hct 38% (37% to 47%), WBC count 12,000/mm3 (5,000 to 10,000/mm3), Prealbumin 12 mg/dL (15 to 36 mg/dL)
- Temperature
- WBC count
- Prealbumin level
- Pain Level
- Odor of wound
A client who is nonambulatory notifies the nurse that his trash can is on fire. After the nurse confirms the presence of the fire, which of the following actions should the nurse take next?
Evacuate the client.
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?
Wrap monitoring cords with stockinette and tape them in place.
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?
"The pain is like a dull ache in my stomach."
A nurse is performing a Romberg test during the physical assessment of a client. Which of the following techniques should the nurse use?
Have the client stand with their arms at their sides and their feet together.
A nurse is teaching a client whose left leg is in a cast about using crutches. Which of the following statements should the nurse identify as an indication that the client understands the teaching?
"When descending stairs, I will first shift my weight to my right leg."
A nurse is calculating a client's fluid intake over the past 8 hr. Which of the following items should the nurse plan to document on the client's intake and output record as 120 mL of fluid?
8 oz of ice chips
A nurse is performing a peripheral vascular assessment for a client. When placing the bell of the stethoscope on the client's neck, the nurse hears the following sound. This sound indicates which of the following? (Click on the audio button to listen to the clip.)
Narrowed arterial lumen
Complete the following sentence by using the lists of options.

A nurse is caring for a client who has a newly placed ileostomy.

Exhibit 1:
Nurses' Notes: 0800: Client is 2 days postoperative following an ileostomy. Pouch is one-fourth full of stool. Stoma is red. Abdomen is soft and nontender. Bowel sounds present in all quadrants.

1200: Stoma site appears dark purple with blistering on the skin around the stoma. Pouch is slightly leaking and is three-fourths full of brown, liquid stool.

Exhibit 2:
Diagnostic Results: 1200:Hgb 19 g/dL (12 to 16 g/dL), Hct 46% (37% to 47%)
The nurse should first address the stoma color followed by the skin around the stoma.
A nurse is caring for a client who requires an informed consent for a surgical procedure. Which of the following actions is the nurse's responsibility?
Witness the client's signature on the consent form.
A home health nurse is completing an admission assessment of an older adult client who has their caregiver present. Which of the following findings should the nurse identify as a potential indication of elder abuse?
The caregiver insists on remaining in the room.
A nurse is caring for a client who is receiving fluid through a peripheral IV catheter. Which of the following findings at the IV site should the nurse identify as indicating infiltration?
Skin blanching
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.
The nurse should first inject air into the vial of NPH insulin without touching the needle to the solution. Next, the nurse should inject air into the vial of regular insulin and withdraw the correct amount of the regular insulin. Finally, the nurse should insert the needle into the NPH insulin vial and withdraw the correct amount of NPH insulin. The nurse should follow these steps to prevent contaminating the regular insulin with NPH insulin.
A nurse is caring for a client who has tuberculosis. Which of the following actions should the nurse take? (Select all that apply.)
- Place the client in a room with negative-pressure airflow
- Wear gloves when assisting the client with oral care
- Use antimicrobial sanitizer for hand hygiene
Complete the following sentence by using the lists of options.

A nurse is caring for a client.

Exhibit 1:
Medical History: Client is receiving chemotherapy for treatment of breast cancer.

Exhibit 2:
Diagnostic Results: Week 1: Hct 42% (37% to 47%), Hgb 15 g/dL (12 g/dL to 16 g/dL), WBC count 8,000/mm3 (5,000 to 10,000/mm3), Platelet count 350,000/mm3 (150,000 to 400,000/mm3)Potassium 3.7 mEq/L (3.5 to 5 mEq/L)

Week 2: Hct 37% (37% to 47%), Hgb 12 g/dL (12 g/dL to 16 g/dL), WBC count 6,000/mm3 (5,000 to 10,000/mm3), Platelet count 100,000/mm3 (150,000 to 400,000/mm3), Potassium 3.6 mEq/L (3.5 to 5 mEq/L)
The client is at risk for bleeding as evidenced by the client's platelet count.
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?
Withhold the blood transfusion.
A nurse is caring for a client who is receiving pain medication through a patient-controlled analgesia (PCA) pump. Which of the following actions should the nurse take?
Instruct the family to refrain from pushing the button for the client while she is asleep.
Complete the following sentence by using the lists of options.

A nurse in a medical-surgical unit is caring for six clients.

Exhibit 1:
Nurses' Notes​: 0800: Client 1: Client is admitted with a new diagnosis of rheumatoid arthritis.
Client 2: Client has a history of hyperlipidemia. Atorvastatin 20 mg PO administered as prescribed.
Client 3: Client is 1 day postoperative. Reports pain as 8 on a scale of 0 to 10. Morphine 5 mg subcutaneous administered as prescribed.
Client 4: Client is admitted with a new diagnosis of heart failure.
Client 5: Client has a stage 2 pressure injury on the left heel.
Client 6: Client is admitted with a new diagnosis of diabetes mellitus.

Exhibit 2:
Diagnostic Results​ 0900: Client 1: C-reactive protein 3.2 mg/dL (less than 1.0 mg/dL)
Client 2: Cholesterol 250 mg/dL (less than 200 mg/dL)
Client 3: Oxygen saturation 88% (95% to 100%)
Client 4: Potassium 3.2 mEq/L (3.5 to 5.0 mEq/L)
Client 5: Prealbumin 14 mg/dL (15 to 36 mg/dL)
Client 6: Glycosylated hemoglobin 8% (less than 7%)
The first client the nurse should asses is client 3 followed by client 4
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?
"I can take echinacea to improve my immune system."
A nurse is planning care for a client who has tuberculosis. The nurse should use which of the following pieces of personal protective equipment when providing care for the client?
N95 respirator
A nurse is caring for a client who has decreased mobility. Which of the following actions should the nurse take to decrease the client's risk of developing plantar flexion contractures?
Apply an ankle-foot orthotic device to the client's feet.
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?
"You should have a fecal occult blood test every year."
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?
Tell the client to keep the head of the bed elevated at least 30°.
A nurse in an acute care facility is preparing a discharge summary for a client who is transferring to a long-term care facility. Which of the following documentation should the nurse include?
Current medications
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?
Distended neck veins
The nurse is reviewing the client's medical record. Which of the following actions should the nurse take? Select all that apply.

A nurse is admitting a client.

Exhibit 1:
Nurses' Notes: 0930: Client reports a sore throat, productive cough, shortness of breath, and fever for the past 4 days.

1030:Client has swollen lymph nodes of the neck upon palpation. Client reports chills and coughs up yellow-colored mucus. Client's face is flushed and diaphoretic. States lack of appetite. Chest x-ray obtained and positive for pneumonia.

Exhibit 2:
Vital Signs: 1030: Blood pressure 110/68 mm Hg, Heart rate 110/min, Respiratory rate 24/min, Temperature 38.6° C (101.5° F), Oxygen saturation 91% on room air
- Place the client on droplet isolation precautions.
- Apply oxygen at 2 L/min via nasal cannula.
- Request a prescription for an antipyretic medication.
- Remain 1 m (3 feet) from the client.
A nurse is caring for a client who reports difficulty falling asleep. Which of the following recommendations should the nurse make?
"Maintain a consistent time to wake up each day."
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?
"We can talk about advance directives, and I can also give you some brochures about them."
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?
Flush the tube with 15 mL of sterile water.
The nurse is reviewing the client's medical record. Click to highlight the findings that require intervention by the nurse.

A nurse is caring for a client who had a spinal cord injury and has paraplegia.

Exhibit 1:
Nurses' Notes: Day 1: Client is alert and oriented. Client is repositioned every 2 hr. Passive range-of-motion exercises to lower extremities performed once each day.

Day 5:Client is alert and oriented. Client is repositioned every 2 hr. Passive range-of-motion exercises to lower extremities performed once each day. Feet warm. Pedal pulses 2+ bilaterally. Plantar flexion contractures noted bilaterally. Left heel with 1.3 cm x 1.3 cm (0.5 in x 0.5 in) area of nonblanchable erythema, skin intact.
- Passive range-of-motion exercises to lower extremities performed once each day.
- Plantar flexion contractures noted bilaterally.
- Left heel with 1.3 cm x 1.3 cm (0.5 in x 0.5 in) area of nonblanchable erythema, skin intact
A nurse is planning teaching for a group of adolescents who each recently had surgical placement of an ostomy. Which of the following methods should the nurse use as a psychomotor approach to learning?
Practice sessions
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?
0.3 mg
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?
Gently shake the container of medication prior to administration.
A nurse is preparing to obtain a lower extremity blood pressure from a client and no longer palpates the popliteal pulse after 92 mm Hg. Which of the following images displays the measurement in mm Hg to which the nurse should inflate the cuff when obtaining the blood pressure?
120 mm Hg
The nurse is reviewing the client's medical record. Which of the following actions should the nurse take? Select all that apply.

A nurse is admitting a client who reports experiencing a sore throat, productive cough, and fever for the past 3 days.

Exhibit 1:
Nurses' Notes: 1000: Client reports sore throat, productive cough with yellow-colored mucus, and fever for the past 3 days. Client has swollen lymph nodes. Client also reports headache that, "won't go away." Client's face is flushed and diaphoretic. Throat culture and blood work obtained as prescribed.

Exhibit 2:
Vital Signs: 1000: Blood pressure 132/68 mm Hg, Heart rate 99/min, Respiratory rate 20/min, Temperature 38.3° C (101° F), Oxygen saturation 96% on room air

Exhibit 3:
Diagnostic Results: 1100: Positive throat culture for streptococci bacteria.
- Request a prescription for an antibiotic medication.
- Initiate droplet precautions.
- Wear a mask within 1 m (3 feet) of the client.
- Apply a mask on the client when they leave their room.
A nurse manager is overseeing the care activities on a unit. For which of the following situations should the nurse manager intervene due to a violation of HIPAA guidelines?
A nurse asks a nurse from another unit to assist with documentation for a client.
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?
"People in middle adulthood often find satisfaction in nurturing and guiding young people."
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?
Arrange food in a consistent pattern on the client's plate.
A nurse on a medical unit is preparing to discharge a client to home. Which of the following actions should the nurse take as part of the medication reconciliation process?
Compare prescriptions with medications the client received while at the facility.
A nurse is administering IV fluids to a client. When monitoring for adverse effects, which of the following assessments should the nurse identify as the priority?
Auscultate lung sounds.
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