RN Fundamentals 2016 70 Questions
1. A nurse is assessing a client who reports pain after a procedure. Which question best evaluates the quality of the pain?
A. Is the pain constant or does it come and go?
B. On a scale of 0 to 10, how severe is your pain?
C. Does the pain spread to other areas?
D. Is the pain sharp or dull in nature?
Explanation: Assessing the quality of pain, such as whether it is sharp or dull, helps in identifying the type of pain and potential underlying causes, guiding appropriate interventions.
2. A nurse is educating a client on managing high cholesterol through diet. Which food should the nurse recommend including?
A. Beef liver
B. Shrimp
C. Egg yolks
D. Avocados
Explanation: Avocados are rich in healthy monounsaturated fats that can help lower bad cholesterol levels while raising good cholesterol, supporting heart health.
3. A nurse is demonstrating ethical principles while caring for clients. Which action shows veracity?
A. Honestly informing a client about their cancer diagnosis when asked.
B. Respecting a client’s refusal of a feeding tube.
C. Following a DNR order despite family protests.
D. Administering pain medication as promised before a procedure.
Explanation: Veracity involves truth-telling, so directly answering a client’s question about their diagnosis upholds this ethical principle.
4. A nurse is checking deep tendon reflexes. Which technique correctly elicits the patellar reflex?
A. Tapping just below the kneecap.
B. Tapping above the kneecap.
C. Tapping the inner thigh.
D. Tapping the outer knee.
Explanation: The patellar reflex is elicited by tapping the patellar tendon just below the kneecap, testing the L2-L4 spinal segments.
5. A postoperative client exhibits signs of hemorrhagic shock. The surgeon instructs monitoring vitals every 15 minutes and calling back in an hour. What should the nurse do next?
A. Note the instruction in the chart.
B. Inform the nursing supervisor.
C. Contact the risk management team.
D. File an incident report.
Explanation: Notifying the nursing manager escalates the concern when a provider’s order may not adequately address a critical situation, ensuring patient safety.
6. A nurse is witnessing informed consent. Which client’s signature can the nurse legally witness?
A. A teacher for a 7-year-old student.
B. A 16-year-old who is married.
C. A parent for their adult child with dementia.
D. A guardian for an unrelated minor.
Explanation: Emancipated minors, such as married teenagers, can provide their own consent for treatment under legal guidelines.
7. To prevent infection spread, which measure should a nurse implement for a client with tuberculosis?
A. Use mesh bags for soiled linens.
B. Place in a negative-pressure airflow room.
C. Provide disposable utensils for HIV clients.
D. Double-bag blood-saturated dressings.
Explanation: Negative-pressure rooms prevent airborne pathogens like TB from spreading to other areas, maintaining isolation.
8. A nonambulatory client reports a fire in their trash can. After confirming, what is the nurse’s next action?
A. Sound the fire alarm.
B. Use an extinguisher on the fire.
C. Evacuate the client from the room.
D. Close doors to contain the fire.
Explanation: In the RACE protocol (Rescue, Alarm, Contain, Extinguish), rescuing or evacuating the client is the priority to ensure safety.
9. After inserting a nasogastric tube, which finding confirms proper placement?
A. Aspirate with a pH of 7.
B. X-ray showing tube tip in the stomach.
C. Presence of bowel sounds.
D. Client feels less nauseated.
Explanation: An abdominal X-ray is the gold standard for confirming NG tube placement in the stomach, preventing complications like aspiration.
10. When starting IV therapy on an older adult, which action should the nurse take?
A. Use the back of the hand for insertion.
B. Massage the venipuncture site firmly.
C. Avoid using a tourniquet.
D. Stabilize the vein by pulling skin downward.
Explanation: Older adults have fragile veins, so inserting without a tourniquet reduces the risk of vein rupture or hematoma formation.
11. A client with advanced prostate cancer declines to discuss concerns after the provider leaves. What should the nurse say?
A. I’ll document this now.
B. Many live long with this condition.
C. I’m here if you want to talk later.
D. I’ll refer you to a support group.
Explanation: Offering availability respects the client’s autonomy and provides emotional support without pressure.
12. A nurse plans aromatherapy for clients. For which client should the nurse consult the provider first?
A. History of abuse.
B. Has a pacemaker.
C. Ulcerative colitis.
D. Asthma diagnosis.
Explanation: Certain essential oils can trigger asthma exacerbations, so consulting ensures safety for clients with respiratory conditions.
13. To auscultate the pulmonary valve in a client with a heart murmur, where should the nurse place the stethoscope?
A. Second intercostal space, left sternal border.
B. Fourth intercostal space, right sternal border.
C. Fourth intercostal space, left sternal border.
D. Second intercostal space, right sternal border.
Explanation: The pulmonary valve area is at the second intercostal space on the left sternal border, optimal for hearing related sounds.
14. A nurse teaches crutch use to a client with a left leg cast. Which statement shows understanding?
A. When going down stairs, I shift my weight to my good leg first.
B. Place crutches 12 inches ahead and to the side.
C. Hold both crutches in one hand when sitting.
D. Ensure shoulder rests fit snugly under armpits.
Explanation: For descending stairs, weight shifts to the unaffected leg first, followed by the crutches and the affected leg, maintaining balance.
15. A client has a sodium level of 125 mEq/L. Which finding should the nurse anticipate?
A. Numbness in limbs.
B. Slow heart rate.
C. Positive Chvostek’s sign.
D. Cramping in the abdomen.
Explanation: Hyponatremia can cause gastrointestinal symptoms like abdominal cramps due to fluid shifts and cellular swelling.
16. A nurse cares for a client who speaks a different language. When using an interpreter, what should the nurse do?
A. Address the client directly.
B. Use a family member as interpreter.
C. Require interpreter’s degree verification.
D. Avoid personal questions through the interpreter.
Explanation: Speaking directly to the client promotes engagement and accuracy in communication via the interpreter.
17. A nurse educates on oxygen therapy. What is a key point for nasal cannula use?
A. Read flow at the top of the ball.
B. Do not exceed 6 L/min flow rate.
C. Deflate the rebreathing mask bag.
D. Use petroleum jelly on the nares.
Explanation: Nasal cannulas deliver low-flow oxygen; rates above 6 L/min can dry mucous membranes and cause discomfort.
18. During assessment of an older adult, which sign suggests possible abuse?
A. Reduced skin elasticity on hands.
B. Varicose veins in legs.
C. Thick, ridged nails.
D. Bruises in different healing stages on arms.
Explanation: Multiple bruises at varying stages may indicate repeated non-accidental injuries, warranting abuse investigation.
19. A nurse documents an 8-hour fluid intake. Which equals 120 mL?
A. 2 cups of soup.
B. 1 quart of water.
C. 8 oz melted ice chips.
D. 6 oz tea.
Explanation: Ice chips melt to half their volume, so 8 oz (240 mL) of ice equals 120 mL of fluid when melted.
20. For a client with fluid volume excess, what should the nurse do first?
A. Limit sodium in diet.
B. Give a diuretic.
C. Check electrolyte balances.
D. Restrict fluids by mouth.
Explanation: Assessing electrolytes identifies imbalances that could worsen with interventions, guiding safe management.
21. A nurse finds a client on the floor post-fall. What should be documented?
A. Completed incident form.
B. Client went over the bed rails.
C. Client discovered on the floor.
D. Client tried to exit bed.
Explanation: Documentation should be objective, stating facts like finding the client on the floor, avoiding assumptions.
22. A client with a respiratory infection reports a past rash from an antibiotic. What should the nurse advise?
A. Rashes often resolve without issue.
B. Many drugs cause side effects.
C. Antibiotics unlikely for viruses.
D. Specify the exact antibiotic used.
Explanation: Identifying the specific antibiotic helps confirm allergies and select safe alternatives.
23. Transferring a client who bears weight on one leg from bed to chair, what is next after setup?
A. Rock to standing.
B. Pivot on the far foot.
C. Check for hypotension.
D. Secure gait belt.
Explanation: Assessing for orthostatic hypotension prevents falls during position changes.
24. An IV of 0.9% NaCl at 125 mL/hr infuses only 80 mL in 2 hours. What first?
A. Reposition client.
B. Record intake.
C. Get new order.
D. Inspect tubing for kinks.
Explanation: Checking for obstructions like kinks ensures proper flow before other actions.
25. For a client with recurrent seizures, what should be in the care plan?
A. Pad all bed sides.
B. Restrain during seizures.
C. Place supine in seizures.
D. Have tongue blade ready.
Explanation: Padding bed rails prevents injury during seizures without restricting movement.
26. Which clients’ informed consents can a nurse witness? (Select all that apply)
A. Teacher for 7-year-old.
B. Married a 16-year-old.
C. 27-year-old with schizophrenia.
D. Adoptive parent for 8-year-old. E. 17-year-old mom for toddler.
Explanation: Emancipated minors (B, E) and competent adults (C) can consent; adoptive parents (D) can consent for minors.
27. In a client with a pressure injury, which lab value is anticipated?
A. Albumin 3 g/dL.
B. HDL 90 mg/dL.
C. Norton score 28.
D. Braden score 20.
Explanation: Low albumin indicates malnutrition, impairing wound healing in pressure ulcers.
28. Administering enoxaparin subcutaneously, what should the nurse do?
A. Use a 45-degree angle.
B. Choose nondominant arm.
C. Bunch skin before injection.
D. Rub site post-injection.
Explanation: A 45-degree angle is appropriate for subcutaneous injections in areas with less fat.
29. A nurse performs hand hygiene. When is alcohol-based sanitizer preferred over soap?
A. After visible soiling.
B. When hands are not soiled.
C. Before eating.
D. Afremovalal, if torn.
Explanation: Alcohol sanitizer is effective for non-soiled hands, killing microbes quickly.
30. For contact precautions, which PPE is essential?
A. Mask and goggles.
B. Gloves and gown.
C. N95 respirator.
D. Shoe covers only.
Explanation: Gloves and a gown prevent direct contact with infectious materials in contact isolation.
31. Measuring blood pressure, which action ensures accuracy?
A. Use a cuff too small.
B. Inflate to 100 mmHg.
C. Place the cuff at the heart level.
D. Take immediately after exercise.
Explanation: Positioning the arm at heart level prevents gravitational errors in readings.
32. A nurse applies pulse oximetry. Which factor can cause false low readings?
A. Nail polish.
B. Warm extremities.
C. Upright position.
D. Bright lighting.
Explanation: Nail polish absorbs light, interfering with the sensor’s oxygen saturation measurement.
33. Changing a wound dressing, which step maintains sterility?
A. Touch the inner dressing surface.
B. Use non-sterile gloves.
C. Open the package away from the body.
D. Apply dressing with bare hands.
Explanation: Opening away from the body keeps the sterile field uncontaminated.
34. The six rights of medication administration include all except:
A. Right dose.
B. Right route.
C. Right time.
D. Right color.
Explanation: Medication color is not a standard right; the rights focus on patient, drug, dose, route, time, and documentation.
35. A nurse delegates to an assistive personnel. Which task is appropriate?
A. Assess pain level.
B. Take vital signs.
C. Administer oral meds.
D. Insert catheter.
Explanation: Assistive personnel can measure vital signs under nurse supervision, but not assess or administer meds.
36. Prioritizing care, which client should the nurse see first?
A. Stable post-op.
B. Mild pain.
C. Sudden dyspnea.
D. Routine dressing change.
Explanation: Sudden shortness of breath indicates a potential airway issue, requiring immediate attention per ABCs.
37. Demonstrating cultural competence, a nurse should:
A. Assume all clients share values.
B. Ask about cultural preferences.
C. Use only English materials.
D. Ignore religious practices.
Explanation: Inquiring about preferences respects diversity and tailors care effectively.
38. In end-of-life care, which intervention promotes comfort?
A. Withhold pain meds.
B. Force oral intake.
C. Provide mouth care.
D. Limit family visits.
Explanation: Frequent mouth care prevents dryness and discomfort in dying clients.
39. Using restraints, the nurse must:
A. Tie to the bed frame.
B. Check every 4 hours.
C. Obtain provider order.
D. Use for convenience.
Explanation: Restraints require a time-limited order and are a last resort for safety.
40. Which action violates HIPAA?
A. Discuss care in private.
B. Share info with team.
C. Talk about the client in the elevator.
D. Use secure electronic records.
Explanation: Discussing patient information in public areas breaches confidentiality.
41. Advance directives include:
A. Only DNR orders.
B. Living wills.
C. Insurance forms.
D. Discharge plans.
Explanation: Living wills specify treatment wishes when a client cannot communicate.
42. Using therapeutic communication, a nurse should:
A. Give advice.
B. Ask why questions.
C. Use open-ended questions.
D. Change topics quickly.
Explanation: Open-ended questions encourage clients to express feelings and concerns.
43. Maintaining aseptic technique during the procedure, the nurse should:
A. Reuse sterile gloves.
B. Keep sterile field above waist.
C. Talk over the field.
D. Touch edges of wrappers.
Explanation: Sterile fields must be at or above waist level to prevent contamination.
44. For indwelling catheter care, the nurse should:
A. Clean from back to front.
B. Use antiseptic daily.
C. Secure to prevent pulling.
D. Empty bag when full.
Explanation: Securing the catheter prevents trauma and reduces infection risk.
45. Teaching ostomy care, the nurse advises:
A. Change pouch weekly.
B. Empty when one-third full.
C. Use soap on the stoma.
D. Ignore skin irritation.
Explanation: Emptying at one-third full prevents leaks and maintains skin integrity.
46. For diabetic foot care, the client should:
A. Soak feet in hot water.
B. Cut nails straight across.
C. Inspect feet daily.
D. Wear tight shoes.
Explanation: Daily inspections detect early issues like cuts or blisters, preventing complications.
47. Signs of hypoglycemia include:
A. Dry mouth.
B. Frequent urination.
C. Shakiness and sweating.
D. Fruity breath.
Explanation: Hypoglycemia causes sympathetic responses like tremors and perspiration due to low blood sugar.
48. Managing hyperglycemia, the nurse monitors for:
A. Rapid pulse.
B. Increased thirst.
C. Cold skin.
D. Anxiety.
Explanation: Polydipsia (thirst) occurs in hyperglycemia as the body tries to dilute high blood glucose.
49. A nurse assesses skin turgor. Poor turgor indicates:
A. Overhydration.
B. Dehydration.
C. Infection.
D. Allergy.
Explanation: Delayed return of pinched skin suggests fluid deficit, common in dehydration.
50. In ethical dilemmas, the principle of nonmaleficence means:
A. Do good.
B. Do no harm.
C. Be fair.
D. Be truthful.
Explanation: Nonmaleficence prioritizes avoiding harm to clients in all nursing actions.
