Foundations Exam 2 Study Guide Exam
Questions And Actual Answers.
A 79-year-old resident in a long-term care facility is known to "wander at night" and has fallen in the
past. What is the most appropriate nursing intervention?
a. Place an abdominal restraint on the client during sleeping hours
b. Check the client frequently during the night
c. Leave a radio playing at the bedside to assist in reality orientation
d. Place the client in a room away from the noise and activity of the nurses' station - Answer b. Check
the client frequently during the night
A visiting nurse completes a home assessment and determines the client has a risk of injury related to
decreased vision. Based on this assessment, the client will benefit most from
a. Installing fluorescent lighting throughout the house
b. Becoming oriented to the position of the furniture and stairways
c. Maintaining complete bed rest in a hospital with side rails
d. Applying physical restraints - Answer b. Becoming oriented to the position of the furniture and
stairways
The nurse walks into the room of a client who begins experiencing a tonic-clonic seizure. Which action is
most appropriate?
a. Turn the client onto their side
b. Run to the nurses station to seek help
c. Place a padded tongue in the mouth
d. Keep the client awake for at least four hours after the seizure subsides - Answer a. Turn the client
onto their side
The nurse is assessing the wrist restraints on the client. Which assessment finding would require
immediate attention?
a. 2 finger space between the wrist and restraint
b. Pulse on the right wrist and the restraint
,c. Client complains of tingling in the fingers on the right hand
d. Restraints are secured to the bed with a slip knot - Answer c. Client complains of tingling in the
fingers on the right hand
Which activity surrounding the request and care of restraints can be delegated to the UAP?
a. Requesting an order from the HCP based on the way the client acted during the bath
b. Removing the restraints during the bath to assess the skin
c. Applying the restraints after the order is written by the HCP
d. Evaluating the pulses for good circulation wile taking vital signs - Answer c. Applying the restraints
after the order is written by the HCP
A client falls asleep while smoking in bed and the blanket catches fire. What is the priority nursing
intervention?
a. Report the client for smoking in bed
b. Attempt to extinguish the fire
c. Assist the client to a safe place
d. Close all windows and doors to contain the fire - Answer c. Assist the client to a safe place
The workmen cause an electrical fire in the nurses station when installing a new piece of equipment in
the intensive care unit. A client is on a ventilator at the end of the hall. The first action the nurse should
take is to
a. Pull the fire alarm
b. Attempt to extinguish the fire
c. Call the physician to obtain orders to take the client off the ventilator
d. Use an Ambu-bad and remove the client - Answer a. Pull the fire alarm
One of the most important things that the nurse can do to prevent a client from acquiring a nosocomial
infection is to
a. Practice appropriate hand hygiene
b. Request prophylactic antibiotics for the client
c. Place the client in isolation
,d. Encourage the client to turn, cough, and deep breath every two hours - Answer a. Practice
appropriate hand hygiene
What is the first thing the nurse should do to prevent problems associated with latex allergies?
a. Use non-latex gloves
b. Identify the persons at risk
c. Keep a latex free supply cart available
d. Administer an antihistamine prophylactically - Answer b. Identify the persons at risk
The surgeon asks the nurse to witness an informed consent. The nurse understands that which client is
unable to sign an informed consent?
a. 16-year-old who is married
b. 35-year-old who is depressed
c. 50-year-old who does not speak English
d. 65-year-old who has received a narcotic for pain - Answer d. 65-year-old who has received a narcotic
for pain
A nurse overhears 2 co-workers talking loudly in the hall about the 'crazy lady in rom 515' who threw a
water pitcher at the surgeon after he delivered bad news about her prognosis. What priority nursing
action should the nurse take?
a. Request the hospital chaplain visit the client for moral support
b. Check the medication record for a PRN dose of Lorazipam (ativan) for anxiety
c. Tell the co-workers to lower their voices- you could hear them down the hall
d. Suggest to the co-workers that the hall is an inappropriate place to talk about the client - Answer d.
Suggest to the co-workers that the hall is an inappropriate place to talk about the client
The nurse observes the tech fussing at a client for not using the urinal. The tech threatens to put a
diaper on the client if their behavior doesn't change. This is an example of
a. Assault
b. Battery
c. False imprisonment
, d. Neglect - Answer a. Assault
The client who has been vomiting frequently for 24 hours will likely present with which system-specific
assessment finding?
a. BUN - 15
b. BP increase from 110/70 to 130/80
c. Urine output decrease from 95cc/hr to 55cc/hr
d. Weight changes from 143 lbs to 142 lbs - Answer c. Urine output decrease from 95cc/hr to 55cc/hr
What would be the priority nursing intervention for a client whose BP changes from 140/88 to 88/62?
a. Evaluate mucous membranes
b. Notify HCP
c. Put client in Fowler's position
d. Put client in supine position with legs elevated - Answer d. Put client in supine position with legs
elevated
Which clinical finding indicates the client is experiencing potential fluid volume excess?
a. BP change from 108/78 to 140/90
b. Decreased crackles in lower lung fields
c. HR decreased from 82/min to 70/min
d. Weight from 150 lbs to 151 lbs - Answer a. BP change from 108/78 to 140/90
What is the expected outcome after administration of IV furosemide (Lasix) for a client who has fluid
volume excess?
a. BP change from 108/78 to 140/90
b. HR changes from 72/min to 108/min
c. Decreased crackles in lower lung fields
d. Weight from 142 lbs to 150 lbs - Answer c. Decreased crackles in lower lung fields
Questions And Actual Answers.
A 79-year-old resident in a long-term care facility is known to "wander at night" and has fallen in the
past. What is the most appropriate nursing intervention?
a. Place an abdominal restraint on the client during sleeping hours
b. Check the client frequently during the night
c. Leave a radio playing at the bedside to assist in reality orientation
d. Place the client in a room away from the noise and activity of the nurses' station - Answer b. Check
the client frequently during the night
A visiting nurse completes a home assessment and determines the client has a risk of injury related to
decreased vision. Based on this assessment, the client will benefit most from
a. Installing fluorescent lighting throughout the house
b. Becoming oriented to the position of the furniture and stairways
c. Maintaining complete bed rest in a hospital with side rails
d. Applying physical restraints - Answer b. Becoming oriented to the position of the furniture and
stairways
The nurse walks into the room of a client who begins experiencing a tonic-clonic seizure. Which action is
most appropriate?
a. Turn the client onto their side
b. Run to the nurses station to seek help
c. Place a padded tongue in the mouth
d. Keep the client awake for at least four hours after the seizure subsides - Answer a. Turn the client
onto their side
The nurse is assessing the wrist restraints on the client. Which assessment finding would require
immediate attention?
a. 2 finger space between the wrist and restraint
b. Pulse on the right wrist and the restraint
,c. Client complains of tingling in the fingers on the right hand
d. Restraints are secured to the bed with a slip knot - Answer c. Client complains of tingling in the
fingers on the right hand
Which activity surrounding the request and care of restraints can be delegated to the UAP?
a. Requesting an order from the HCP based on the way the client acted during the bath
b. Removing the restraints during the bath to assess the skin
c. Applying the restraints after the order is written by the HCP
d. Evaluating the pulses for good circulation wile taking vital signs - Answer c. Applying the restraints
after the order is written by the HCP
A client falls asleep while smoking in bed and the blanket catches fire. What is the priority nursing
intervention?
a. Report the client for smoking in bed
b. Attempt to extinguish the fire
c. Assist the client to a safe place
d. Close all windows and doors to contain the fire - Answer c. Assist the client to a safe place
The workmen cause an electrical fire in the nurses station when installing a new piece of equipment in
the intensive care unit. A client is on a ventilator at the end of the hall. The first action the nurse should
take is to
a. Pull the fire alarm
b. Attempt to extinguish the fire
c. Call the physician to obtain orders to take the client off the ventilator
d. Use an Ambu-bad and remove the client - Answer a. Pull the fire alarm
One of the most important things that the nurse can do to prevent a client from acquiring a nosocomial
infection is to
a. Practice appropriate hand hygiene
b. Request prophylactic antibiotics for the client
c. Place the client in isolation
,d. Encourage the client to turn, cough, and deep breath every two hours - Answer a. Practice
appropriate hand hygiene
What is the first thing the nurse should do to prevent problems associated with latex allergies?
a. Use non-latex gloves
b. Identify the persons at risk
c. Keep a latex free supply cart available
d. Administer an antihistamine prophylactically - Answer b. Identify the persons at risk
The surgeon asks the nurse to witness an informed consent. The nurse understands that which client is
unable to sign an informed consent?
a. 16-year-old who is married
b. 35-year-old who is depressed
c. 50-year-old who does not speak English
d. 65-year-old who has received a narcotic for pain - Answer d. 65-year-old who has received a narcotic
for pain
A nurse overhears 2 co-workers talking loudly in the hall about the 'crazy lady in rom 515' who threw a
water pitcher at the surgeon after he delivered bad news about her prognosis. What priority nursing
action should the nurse take?
a. Request the hospital chaplain visit the client for moral support
b. Check the medication record for a PRN dose of Lorazipam (ativan) for anxiety
c. Tell the co-workers to lower their voices- you could hear them down the hall
d. Suggest to the co-workers that the hall is an inappropriate place to talk about the client - Answer d.
Suggest to the co-workers that the hall is an inappropriate place to talk about the client
The nurse observes the tech fussing at a client for not using the urinal. The tech threatens to put a
diaper on the client if their behavior doesn't change. This is an example of
a. Assault
b. Battery
c. False imprisonment
, d. Neglect - Answer a. Assault
The client who has been vomiting frequently for 24 hours will likely present with which system-specific
assessment finding?
a. BUN - 15
b. BP increase from 110/70 to 130/80
c. Urine output decrease from 95cc/hr to 55cc/hr
d. Weight changes from 143 lbs to 142 lbs - Answer c. Urine output decrease from 95cc/hr to 55cc/hr
What would be the priority nursing intervention for a client whose BP changes from 140/88 to 88/62?
a. Evaluate mucous membranes
b. Notify HCP
c. Put client in Fowler's position
d. Put client in supine position with legs elevated - Answer d. Put client in supine position with legs
elevated
Which clinical finding indicates the client is experiencing potential fluid volume excess?
a. BP change from 108/78 to 140/90
b. Decreased crackles in lower lung fields
c. HR decreased from 82/min to 70/min
d. Weight from 150 lbs to 151 lbs - Answer a. BP change from 108/78 to 140/90
What is the expected outcome after administration of IV furosemide (Lasix) for a client who has fluid
volume excess?
a. BP change from 108/78 to 140/90
b. HR changes from 72/min to 108/min
c. Decreased crackles in lower lung fields
d. Weight from 142 lbs to 150 lbs - Answer c. Decreased crackles in lower lung fields
