RN Fundamentals Exam 3 Versions
NGN-Style 2026/2027 – 100%
Verified Questions & Answers | A+
Graded Pass Guaranteed
1. A nurse is caring for a client who is postoperative following
abdominal surgery. Which of the following actions should the
nurse take first to prevent complications related to
immobility?
A. Assist the client to perform range-of-motion exercises.
B. Encourage the client to use an incentive spirometer.
C. Turn the client every 2 hours.
D. Administer a prescribed stool softener.
Rationale: The first and most critical complication to prevent after
abdominal surgery is respiratory compromise, such as atelectasis
and pneumonia. Using an incentive spirometer promotes lung
expansion and is a priority nursing intervention. While turning and
range-of-motion exercises are important, respiratory status takes
precedence. Stool softeners are not the first priority.
2. A nurse is assessing four clients. Which client should the
nurse see first?
,A. A client who is 1 day postoperative and reports pain at a 6 on a
0 to 10 scale.
B. A client with a new onset of confusion and a temperature
of 38.9°C (102°F).
C. A client who is requesting pain medication for a headache.
D. A client who needs assistance with ambulation.
Rationale: A new onset of confusion combined with a fever is a
classic sign of a new infection, possibly sepsis or a urinary tract
infection, especially in an older adult. This is a change in mental
status that indicates a potential medical emergency. The nurse
must use the ABCs (Airway, Breathing, Circulation) and Maslow's
hierarchy to prioritize, and this client shows signs of a systemic
issue that requires immediate assessment and intervention.
3. A nurse is preparing to administer a medication via a
nasogastric (NG) tube. Which of the following actions should
the nurse take?
A. Administer the medication rapidly to prevent clogging the
tube.
B. Verify tube placement by aspirating gastric contents and
checking pH.
C. Mix all medications together in one syringe for efficiency.
D. Position the client in a supine position before administration.
Rationale: The most critical safety step before administering any
medication via an NG tube is to verify its placement. The gold
standard is to aspirate gastric contents and check the pH, which
,should be 5.5 or lower. Administering medication into the lungs (if
the tube is misplaced) can be fatal. Medications should be given
separately, and the client should be in a semi-Fowler's position to
prevent aspiration.
4. A nurse is teaching a client about the use of a cane. Which
of the following instructions should the nurse include?
A. "Hold the cane on your weaker side."
B. "The top of the cane should be at the level of your greater
trochanter."
C. "Move the cane forward first, then your stronger leg."
D. "Lean your body weight over the cane when walking."
Rationale: For proper fit, the handle of the cane should be at the
level of the client's greater trochanter or wrist crease when the arm
is hanging at the side. The cane is held on the stronger side to
provide support to the weaker side. The correct gait is to move the
cane and the weaker leg forward together, followed by the stronger
leg. Leaning over the cane can cause imbalance.
5. A nurse is caring for a client who has an order for strict
intake and output (I&O) monitoring. Which of the following
should the nurse include in the intake record?
A. The volume of a wound vacuum-assisted closure (VAC) canister.
B. The amount of ice chips the client consumed.
, C. The amount of fluid used for a bed bath.
D. The estimated amount of blood loss during a dressing change.
Rationale: Intake includes all fluids a client takes in by mouth,
tube feedings, and intravenous fluids. Ice chips are considered part
of the oral intake and should be recorded as half their volume.
Output includes urine, emesis, wound drainage, and stool. The fluid
used for a bath is not intake, and blood loss is considered output.
6. A nurse is performing a skin assessment on an older adult
client. Which of the following findings should the nurse
report to the provider?
A. A general decrease in skin turgor.
B. A purplish, non-blanchable area on the sacrum.
C. Decreased hair growth on the lower legs.
D. A small, flat, brown mole on the back.
Rationale: A purplish, non-blanchable area is a definitive sign of a
stage 1 pressure injury. This must be reported to the provider and
documented, and interventions should be initiated immediately to
prevent further breakdown. A decrease in skin turgor and hair
growth are common age-related changes. A stable mole should be
documented but does not require immediate reporting.
7. A nurse is implementing a fall prevention plan for a client.
Which of the following interventions is the priority?
NGN-Style 2026/2027 – 100%
Verified Questions & Answers | A+
Graded Pass Guaranteed
1. A nurse is caring for a client who is postoperative following
abdominal surgery. Which of the following actions should the
nurse take first to prevent complications related to
immobility?
A. Assist the client to perform range-of-motion exercises.
B. Encourage the client to use an incentive spirometer.
C. Turn the client every 2 hours.
D. Administer a prescribed stool softener.
Rationale: The first and most critical complication to prevent after
abdominal surgery is respiratory compromise, such as atelectasis
and pneumonia. Using an incentive spirometer promotes lung
expansion and is a priority nursing intervention. While turning and
range-of-motion exercises are important, respiratory status takes
precedence. Stool softeners are not the first priority.
2. A nurse is assessing four clients. Which client should the
nurse see first?
,A. A client who is 1 day postoperative and reports pain at a 6 on a
0 to 10 scale.
B. A client with a new onset of confusion and a temperature
of 38.9°C (102°F).
C. A client who is requesting pain medication for a headache.
D. A client who needs assistance with ambulation.
Rationale: A new onset of confusion combined with a fever is a
classic sign of a new infection, possibly sepsis or a urinary tract
infection, especially in an older adult. This is a change in mental
status that indicates a potential medical emergency. The nurse
must use the ABCs (Airway, Breathing, Circulation) and Maslow's
hierarchy to prioritize, and this client shows signs of a systemic
issue that requires immediate assessment and intervention.
3. A nurse is preparing to administer a medication via a
nasogastric (NG) tube. Which of the following actions should
the nurse take?
A. Administer the medication rapidly to prevent clogging the
tube.
B. Verify tube placement by aspirating gastric contents and
checking pH.
C. Mix all medications together in one syringe for efficiency.
D. Position the client in a supine position before administration.
Rationale: The most critical safety step before administering any
medication via an NG tube is to verify its placement. The gold
standard is to aspirate gastric contents and check the pH, which
,should be 5.5 or lower. Administering medication into the lungs (if
the tube is misplaced) can be fatal. Medications should be given
separately, and the client should be in a semi-Fowler's position to
prevent aspiration.
4. A nurse is teaching a client about the use of a cane. Which
of the following instructions should the nurse include?
A. "Hold the cane on your weaker side."
B. "The top of the cane should be at the level of your greater
trochanter."
C. "Move the cane forward first, then your stronger leg."
D. "Lean your body weight over the cane when walking."
Rationale: For proper fit, the handle of the cane should be at the
level of the client's greater trochanter or wrist crease when the arm
is hanging at the side. The cane is held on the stronger side to
provide support to the weaker side. The correct gait is to move the
cane and the weaker leg forward together, followed by the stronger
leg. Leaning over the cane can cause imbalance.
5. A nurse is caring for a client who has an order for strict
intake and output (I&O) monitoring. Which of the following
should the nurse include in the intake record?
A. The volume of a wound vacuum-assisted closure (VAC) canister.
B. The amount of ice chips the client consumed.
, C. The amount of fluid used for a bed bath.
D. The estimated amount of blood loss during a dressing change.
Rationale: Intake includes all fluids a client takes in by mouth,
tube feedings, and intravenous fluids. Ice chips are considered part
of the oral intake and should be recorded as half their volume.
Output includes urine, emesis, wound drainage, and stool. The fluid
used for a bath is not intake, and blood loss is considered output.
6. A nurse is performing a skin assessment on an older adult
client. Which of the following findings should the nurse
report to the provider?
A. A general decrease in skin turgor.
B. A purplish, non-blanchable area on the sacrum.
C. Decreased hair growth on the lower legs.
D. A small, flat, brown mole on the back.
Rationale: A purplish, non-blanchable area is a definitive sign of a
stage 1 pressure injury. This must be reported to the provider and
documented, and interventions should be initiated immediately to
prevent further breakdown. A decrease in skin turgor and hair
growth are common age-related changes. A stable mole should be
documented but does not require immediate reporting.
7. A nurse is implementing a fall prevention plan for a client.
Which of the following interventions is the priority?
