FUNDAMENTALS OF NURSING

1. A client arrives at the surgical unit after nasal surgery. The client has nasal packing in place. The nurse
reviews the physician's orders and anticipates that which of the following client positions would be
prescribed to reduce swelling?

a. sim's
b. Prone
c. Supine
d. Semi-Fowler's *

2. A client enters the emergency department with a nosebleed. On assessment, the client tells the
nurse that the nosebleed just suddenly began. The nurse notes no obvious facial injury. Which of the
following would be the initial nursing action?

a. Prepare a nasal baloon for insertion

b. Insert nasal packing
c. Sit the client down, ask the client to lean forward, and apply pressure to the nose for 5 to 10
minutes.*
d. Place the client in a semi-fowlers position and apply ice packs to the nose.

3. A nurse is caring for a client who is receiving total parenteral nutrition (TPN) via a central line.
Which nursing intervention would specifically provide assessment data related to the most common
complication related to TPN?

a. weighing the client daily

b. Monitoring I&O
c. Monitoring the temperature *
d. Monitoring the serum blood urea nitrogen (BUN)

4. A nurse has developed a teaching plan for an elderly client with hypertension about the
administration of prescribed medications. The initial nursing action would be to do which of the
following?

a. Assess the client's readiness to learn *

b. Find out if anyone lives with the client
c. Set priorities for the client
d. Use only one teaching method to prevent confusion

5. A female client tells the home health nurse that she has not had a stool since coming home from
the hospital after surgery 4 days ago. Which of the following is the most appropriate diet for this
client at this time?

a. High-fiber diet*
b. Full-liquid diet
c. Low-residue diet
d. Low-sodium diet

6. A physician has ordered a clear liquid diet for a postoperative client. The nurse prepares to deliver
the lunch tray to the client and checks the food tray to be sure that which of the following is true?

a. Sodiums foods are restricted

b. All food item are lukewarm in temperature
c. All food items are liquid at body temperature *
d. At least one serving of low-fat milk is served.

7. A client is being seen in the clinic for sypmtoms of hyperinsulinism. A nurse provides information
to the client about dietary measures for the condition. Which of the following diets would be most
appropriate to suggest to the client?

a. A low-fiber, high-fat diet

b. Limiting food intake to two meals per day
c. Large amounts of carbohydrates between low-protein meals
d. Small frequent meals with protein, fat, and carbohydrates at each meal *

8. A nurse is developing a plan of care for a client with a nasogastric (NG) tube feeding in place.
When formulating the plan of care, the nurse keeps which of the following in mind?

a. Aspiration is a concern with a nasogastric tube feeding. *

b. The client needs to be maintained in supine position.
c. The NG tube needs to be changed with every other feeding.
d. The rate of the feeding needs to be increased if the infusion rate falls behind schedule.

9. A nurse is preparing a plan of care for a client receiving enteral feedings via a gastrotomy tube (G-
tube). The nurse plans to include which of the following interventions in the plan of care?

a. To provide oral fluids three times per day

b. To check around the stoma site for skin irritation. *
c. To medicate with antidiarrheal medications everyday.
d. To use sterile technique when administering the tube feedings.

10. A nurse is caring for a client with impaired mobility that occurred as a result of a stroke. The client
has right-sided arm and leg weakness. The nurse would suggest that the client use which of the
following assistive devices that would provide the best stability for ambulating?

a. Crutches
b. A single straight-legged cane
c. A quad cane *
d. A walker
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11. A nurse is instructing a client who has had a stroke how to ambulate with the use of a cane.
Which of the following instructions would the nurse provide to the client?

a. Hold the cane on the affected (weak) side.

b. Hold the cane on the unaffected (strong) side. *
c. Move the cane forward first along with the unaffected (strong) leg.
d. When going down stairs, move the cane and the unaffected (strong) leg down first.

12. The home care nurse visits a client who has been experiencing increased weakness. The client
tells the nurse that he is using a cane that was purchased at a local pharmacy. The home care nurse
assesses the client's use of the cane and determines that the cane is sized correctly if which of the
following is true?

a. The handle of the cane is even with client's waist

b. The client's elbow is flexed at a 15 to 30 degree angle when ambulating with the cane. *
c. The client's elbow is flexed at a 50 to 75 degree angle when ambulating with the cane.
d. The client's elbow is straight when ambulating with the cane.

13. A nurse is caring for a client with a diagnosis of dehydration. The client is receiving intravenous
fluids. which of the following assessment data would indicate to the nurse that the dehydration is not
resolved?

a. A urine specific gravity of 1.033 *

b. A urine output that is pale yellow in color.
c. A blood pressure of 120/80 mmHg
d. An oral temperature of 98.8 F

14. A registered nurse (RN) is supervising a licensed practical nurse (LPN) administer an intramuscular
(IM) injection of iron to an assigned client. The RN would intervene if the nurse observed the LPN
perform which of the following?

a. Changing the needle after drawing up the dose and before injection.
b. Preparing an air lock when drawing up the medication
c. Using a Z-tract method for injection.
d. Massaging the injection site well afer injection. *

15. A client is performing an assessment on a client with a diagnosis of pernicious anemia. Which
assessment finding would the nurse expect to note in this client?

a. Shortness of breath on exertion.

b. Dyspnea
c. Red tongue that is smooth and sore *
d. Dusky mucous membrane

16. A clinic nurse is reviewing the record of a client with a suspected diagnosis of pernicious anemia.
The nurse reviews the physician's orders and anticipates thatr which of the following diagnostic tests
will be ordered?

a. Bone marrow biopsy

b. Schilling test *
c. White blood cell differential
d. Clotting time

17. A registered nurse (RN) has instructed a nursing assistant (NA) to administer soap solution
enemas until clear to a client scheduled for a colonoscopy. The NA tells the nurse that three enemas
have been administered and that the client is still passing brown liquid stool. Which of the following
instructions would the RN give to the NA?

a. Wait 30 minutes abd then administer another enema

b. Administer a Fleet enema.
c. Administer an oil-retention enema.
d. Stop administering the enemas until the physician is notified. *

18. A nurse attends an educational conference on leadership styles. The nurse is sitting with a nurse
employed at a large trauma center who states that the leadership style at the trauma center is task-
oriented and directive. The nurse is describing which of the following leadership styles?

a. Autocratic *
b. Situational
c. Democratic
d. Laissez faire

19. A nurse in the emergency room receives a telephone call from emergency medical services and is
told that several victims who survived a plane crash will be transported to the hospital. The nurse is
told that several victims are suffering from cold exposure because the plane plummeted and
submerged into a local river. Which of the following would be the nurse's initial action?

a. Supply the triage rooms with bottles of sterile water and normal saline.
b. Call the laundry department and ask the department to send as many as warm blankets as possible
to the emergency room.
c. Call the nursing supervisor to activate the agency disaster plan. *
d. Call the intensive care unit to request that nurses be sent to the emergency room.

20. The nurse caring for a client with hypocalcemia would expect to note which of the following
changes on the electrocardiogram(ECG)?

a. Prominent U wave
b. Widened T wave
c. Shortened ST segment
d. Prolonged QT interval *

21. The nurse caring for a client with severe malnutrition reviews the laboratory results and notes a
magnesium level of 1.0 mEq/L. Which ECG change would the nurse expect to note based on the
magnesium level?
a. Prominent U wave
b. Depressed ST segment *
c. Widened QRS complex
d. Prologed PR interval
ABG
1. The nurse plans care for a client with chronic obstructive pulmonary disease (COPD) knowing that the
client is most likely to experience what type of acid-base imbalance?

a. Repiratory acidosis *
b. Respiratory alkalosis
c. Metabolic acidosis
d. Metabolic alkalosis

2. The nurse reviews the blood gas results of a client with Guillain-Barre syndrome. The nurse analyzes
the results and determines that the client is experiencing respiratory acidosis. Which of the following
validates the nurse's findings?

a. pH 7.50, PCO2 52mm Hg

b. pH 7.35, PCO2 40 mm Hg
c. pH 7.25, PCO2 50 mm Hg *
d. pH 7.50, PCO2 30 mm Hg

3. The nurse is caring for a client who is on a mechanical ventilator. Blood gas results indicate a pH of
7.50 and a PCO2 of 30mm Hg. The nurse has determined that the client is experiencing respiratory
alkalosis. Which laboratory value would most likely be noted in this condition?

a. Sodium level of 145 mEq/L

b. Potassium level of 3.0 mEq/L *
c. Magnesium level of 2.0 mg/dL
d. Phosphorous level of 4.0 mg/dL

4. The nurse reviews the arterial blood gas results of a client and notes the following: pH of 7.45, PCO2
of 30 mm Hg, and HCO3 of 22 mEQ/L. The nurse analyzes these results as indicating?

a. Metabolic acidosis, compensated

b. Metabolic alkalosis, uncompensated
c. Respiratory alkalosis, compensated *
d. Respiratory acidosis, uncompensated

5. The client is scheduled for blood to be drawn from the radial artery for an arterial blood gas (ABG)
determination. Before the blood is drawn, an Allen test is performed to determine the adequacy of the:

a. Popliteal circulation
b. Ulnar circulation *
c. Femoral circulation
d. Carotid circulation

6. The nurse is caring for a client with a nasogastric tube is attached to low suction. The nurse monitors
the client, knowing that the client is at risk for which acid-base disorder?

a. Respiratory acidosis
b.Respiratory alkalosis
c.Metabolic acidosis
d. Metabolic alkalosis *

7. the nurse is caring for a client with diabetic ketoacidosis and documents that the client is experiencing
Kussmaul's respirations. Based on this documentation, which of the following did the nurse observe?

a. Respirations that are abnormally deep, regular and increased in rate *

b. Respirations that are regular but abnormally slow
c. Respirations that are labored and increased in depth and rate
d. Respirations that cease for several seconds

8. A nurse is reviewing the arterial blood gas values of a client and notes that the pH is 7.31, pCO2 is 50
mm Hg and the bicarbonate level (HCO3) is 27 mEq/L. The nurse concludes that which acid base
disturbance is present in this client?

a. Respiratory acidosis *
b. Respiratory alkalosis
c. Metabolic acidosis
d. Metabolic alkalosis

9. The nurse is caring for a client with renal failure. Blood gas results indicate a pH of 7.30, a PCO2 of 32
mm Hg, and an HCO3 of 20 mEQ/L. The nurse has determined that the client is experiencing metabolic
acidosis. Which of the following laboratory values would the nurse expect to note?

a. Sodium level of 145 mEq/L

b. Magnesium level of 2.0 mg/dL
c. Potassium level of 5.2 mEq/L *
d. Phosphorous level of 4.0 mg/dL

CARDIOVASCULAR
1. A home care nurse has given instructions to a client who is beginning therapy with digoxin(Lanoxin).
The nurse would evaluate that the client needs reinforcement of the instructions if the client made
which of the following statements?

a. " I should call the doctor if my daily pulse rate is under 60 or over 100. "
b. " If I miss a dose, I should just take two the next day. "
c. " I shouldn't change brands without asking the doctor first."
d. " The pills should be kept in the original container so that they don't get mixed up with my other
medicines. "

2. A home care nurse who is visiting a client is preparing to remove a dressing from a leg ulcer, the nurse
notes that the ulcer is pale and deep and is surrounded by tissue that is cool to touch. The nurse would
document that the client's leg ulcer most appropriately identifies which type of ulcer?

a. A vascular ulcer
b. A venous stasis ulcer
c. An arterial ulcer
d. A stage one ulcer

3. A nurse is developing a plan of care for a client who will be admitted to the hospital with diagnosis of
deep vein thrombosis (DVT) of the right leg. The nurse develops the plan expecting that the physiscian
will precribe which of the following?

a. Maintain the affected leg in a dependent position.

b. Apply cool packs to the affected leg for 20 minutes every 4 hours
c. Maintain bed rest
d. Administer a narcotic analgesic every 4 hours around the clock

4. A nurse is monitoring a client with acute pericarditis for signs of cardiac tamponade. Which
assessment finding would indicate the presence of this complication?

a. A pulse rate of 60 beheats per minute

b. Flat neck veins
c. Muffled or distant heart sounds
d. A blood pressure (BP) 0f 128/82 mmHg

5. A clinic nurse is providing instructions to a client with hypertension who will be taking captopril
(Capoten). Which instruction would not be a component of the teaching plan?

a. Drink increased amounts of water

b. Change position slowly
c. Avoid taking hot baths or showers
d. Sit down and rest if dizziness or lightheadedness occurs

6. A nurse is providing instructions to a client with a diagnosis of hypertension about items to avoid that
are high in sodium. The nurse instructs the client to avoid which of the following?

a. Cantaloupe
b. Broccoli
c. Mineral water
d. Bananas

7. A nurse is reviewing the medical record of a client transferred to the medical unit from the critical
care unit. The nurse notes that the client received intraaortic balloon pump (IABP) therapy while in the
critical care unit. The nurse would suspect that the client received this therapy for which the following
conditions?

a. Congestive heart failure

b.Cardiogenic shock
c. Pulmonary edema
d. Aortic insufficiency

8. A nurse in the medical unit is reviewing the laboratory results of a client who has been transferred
from the intensive care unit. The nurse notes that a cardiac troponin T level was drawn on the client
while in the intensive care unit. The nurse determines that this test was performed to assisst in
diagnosing which of the following conditions?

a. Myocardial Infarction
b. Congestive heart failure
c. Ventricular tachycardia
d. Atrial fibrillation

9. A nurse is caring for a client with cardiac disease who has been placed on cardiac monitor. The nurse
notes that the client has developed atrial fibrillation and has a ventricular rate of 150 beats per minute.
The nurse would next assess the client for which of the following?

a. Flat neck veins

b. Complaints of nausea
c. Complaints of headache
d. hypotension

10. A nurse is performing an assessment on a client with a diagnosis of left-sided heart failure. Which
assessment would elicit specific information about the client's left-sided heart function?

a. Listening to lung sounds

b. Assessing for peripheral and sacral edema
c. Assessing for jugular vein distention
d. Monitoring for organomegaly

11. A clinic nurse is reviewing the assessment findings of a client who has been taking spironolactone
(Aldactone) as a treatment for hypertension. Which of the following, if noted in the client's record,
would indicate that the client is experiencing a side effects related to the medication?

a. A potassium level of 3.2 mEq/L

b. A potassium level of 5.8 mEq/L
c. Client complaints of contsipation
d. Client complaints of dry skin

12. A nurse is reviewing the electrocardiogram (ECG) rhythm strip obtained on a client with diagnosis of
myocardial infarction. The nurse notes that the PR interval is 0.20 seconds. The nurse determines that
this is:

a. A normal finding
b. Indicative of atrial flutter
c. Indicative of impending reinfarction
d. Indicative of atrial fibrillation

13. A nurse is documenting information in a client's chart when the ECG telemetry alarm sounds. The
nurse notes that the client is in ventricular tachycardia (VT). The nurse quickly rushes to the bedside and
performs which assessment first?

a. Blood Pressure
b. Cardiac rate
c. Respiratory rate
d. Responsiveness of the client

14. A left catheter is inserted into a client during cardiac surgery. The nurse is monitoring the left atrial
pressure (LAP) and documents that the pressure is normal if which of the following pressure is noted?

a. 8 mm Hg
b. 15 mm Hg
c. 25 mm Hg
d. 32 mm Hg

15. A nurse is developing a plan of care for a client with varicose veins who develops skin breakdown as
a result of the disorder and secondary infection. The nurse includes which of the following as a priority
in the plan of care?

a. Keep the legs aligned with the heart.

b. Position the client onto the side every shift.
c. Clean the skin with alcohol every hour.
d. Elevate the legs higher than the heart.

16. A nurse is assisting in performing an arterial blood gas analysis on a client. The nurse prepares to
initiate which of the following after the blood gas specimen is drawn?

a. Cover the site with 4x4 gauze

b. Apply warm packs to the site
c. Perform range of motion to the fingers of the hand
d. Apply pressure to the site
17. A nurse is caring for a client with a diagnosis of myocardial infarction (MI). The client is experiencing
chest pain that is unrelieved by the administration of nitroglycerin, The nurse administers morphine to
the client as prescribed by the physician. Following administration of the morphine sulfate, the nurse
plans to monitor:

a. Mental status
b. Respirations and blood pressure
c. Urinary output
d. Temperature and blood pressure

18. A nurse is caring for a client with a diagnosis of myocardial infarction (MI). The client calls the nurse
because the client is experiencing chest pain. The nurse administers a sublingual nitroglycerin tablet as
prescribed. The chest pain is unrelieved by the nitroglycerin. The next nursing action is which of the
following?

a. Administer another nitroglycerin tablet

b. Increase the flow rate of the oxygen
c. Contact the physican
d. Call the client's family

19. A nurse is performing an admission assessment of a client with a diagnosis of angina pectoris who
takes nitroglycerin for chest pain at home. During the admission, the client complains of the chest pain.
The nurse would immediately ask the client which of the following questions?
a. " Are you having any nausea? "
*b. "Where is the pain located?"
c. "Are you allergic to any medications?"
d. "Do you have your nitroglycerin with you?"

20. A client si going to have a cardiac catheterization to diagnose the extent of coronary artery disease.
The nurse places highest priority on teaching the client to report which of the following sensations
during the procedure?

a. Pressure at the insertion site

b. Urge to cough
c. Warm, flushed feeling
*d. Chest pain

21. A client admitted to the hospital with coronary artery disease complains of dyspnea at rest. A nurse
caring for the client uses which of the following items as the best means to monitor respiratory status
on an ongoing basis?

a. Oxygen flow meter

*b. Oxygen saturation monitor
c. Telemetry cardiac monitor
d. Apnea monitor

22. A client with a history of anginal pectoris tells the nurse that chest pain usually occurs after going up
two flights of stairs or after walking four blocks. The nurse interprets that the client is experiencing
which of the following types of angina?

a. Stable
b. unstable
c. Variant
d. Intractable

23. A client has experienced an episode of pulmonary edema. The nurse determines that the client's
respiratory status is improving after this episode if which of the following breath sounds is noted?

a. Rales throughout the lung fields

b. Crackles in the bases
c. Wheezes
d. Rhonchi

24. A client is scheduled to begin therapy with acetazolamide (Diamox) for the management of
glaucoma. Prior to the initiating therapy, the nurse assesses the client for a history of allergy or
sensitivity to which of the following?

a. Corticosteroids
b. Nonsteroidal antiinflammatory agents
c. Penicillin
d. Sulfa drugs

25. A client's ECG strip shows atrial and ventricular rates of 70 complexes per minute. The P-R interval is
0.16 second, the QRS complex measures 0.06 second, and the P-R interval is slightly irregular. The nurse
interprets this rhythm to be which of the following?

a. Sinus bradycardia
b. Normal sinus rhythm
c. Sinus tachycardia
d. Sinus arrythmia