Fundamentals practice test B
A nurse receives report about a client who has 0.9% sodium chloride infusing IV at 125 mL/hr.
when the nurse performs the initial assessment, he notes that the client has received only 80 mL
over the last 2 hr. which of the following actions should the nurse take first?
Check the IV tubing for obstruction.
Rationale:
, Fundamentals practice test B
The first action the nurse should take using the nursing process is to assess the client. By
checking the IV tubing for obstruction, the nurse might be able to facilitate the flow of fluid
through the tubing. This could re-establish the infusion rate the provider prescribed.
1. A nurse is caring for a client who is postoperative. When the nurse prepares to change her
dressing she says, “Every time you change my bandage, it hurts so much.” Which of the
following interventions is the nurse’s priority action?
Administer pain medication 45 min before changing the client’s dressing.
Rationale:
The priority action the nurse should take when using Maslow’s hierarchy of needs is to meet the
client’s physiological need for comfort and pain relief. Therefore, the priority intervention is to
administer an analgesic 30 to 60 min before changing the client’s dressing.
2. A nurse is caring for a child who has a prescription for a blood transfusion. The parents have
refused the treatment due to religious beliefs. Which of the following actions should the nurse
take?
Examine the personal values about the issue.
Rationale:
The nurse should examine her own personal values about the issue to help her provide care that
is without bias.
3. 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.”
Rationale:
According to Erikson, the task of middle adulthood is generativity versus self-absorption and
stagnation. The focus on this task is on offering support and guidance to future generations. The
nurse should explore with the client opportunities for mastering the developmental tasks of this
stage such as volunteering and mentoring.
A nurse receives report about a client who has 0.9% sodium chloride infusing IV at 125 mL/hr.
when the nurse performs the initial assessment, he notes that the client has received only 80 mL
over the last 2 hr. which of the following actions should the nurse take first?
Check the IV tubing for obstruction.
Rationale:
, Fundamentals practice test B
The first action the nurse should take using the nursing process is to assess the client. By
checking the IV tubing for obstruction, the nurse might be able to facilitate the flow of fluid
through the tubing. This could re-establish the infusion rate the provider prescribed.
1. A nurse is caring for a client who is postoperative. When the nurse prepares to change her
dressing she says, “Every time you change my bandage, it hurts so much.” Which of the
following interventions is the nurse’s priority action?
Administer pain medication 45 min before changing the client’s dressing.
Rationale:
The priority action the nurse should take when using Maslow’s hierarchy of needs is to meet the
client’s physiological need for comfort and pain relief. Therefore, the priority intervention is to
administer an analgesic 30 to 60 min before changing the client’s dressing.
2. A nurse is caring for a child who has a prescription for a blood transfusion. The parents have
refused the treatment due to religious beliefs. Which of the following actions should the nurse
take?
Examine the personal values about the issue.
Rationale:
The nurse should examine her own personal values about the issue to help her provide care that
is without bias.
3. 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.”
Rationale:
According to Erikson, the task of middle adulthood is generativity versus self-absorption and
stagnation. The focus on this task is on offering support and guidance to future generations. The
nurse should explore with the client opportunities for mastering the developmental tasks of this
stage such as volunteering and mentoring.
