Fundamentals I Q&A
A nurse is reinforcing teaching of postoperative deep breathing and coughing exercises
with a client who will have emergency surgery for appendicitis. Which of the following
statements indicates a lack of readiness to learn by the client? - (correct answer)The
client reports severe pain
A nurse is caring for a client who has a terminal illness. The client asks several
questions about the nurses religious beliefs related to death and dying. Which of the
following actions should the nurse take? - (correct answer)Encourage the client to
express his thoughts about death and dying.
A nurse is measuring vital signs for a client and notices an irregularity in the pulse.
Which of the following actions should the nurse take? - (correct answer)Count the apical
pulse rate for 1 full minute, and describe the rhythm in the chart.
A nurse on a medical-surgical unit is caring for a client. Which of the following actions
should the nurse take first when using the nursing process. - (correct answer)Obtain
client information
A nurse is planning weight loss strategies for a group of clients who are obese. Which of
the following actions by the nurse will improve the clients commitment to a long-term
goal of weight loss. - (correct answer)Attempt to increase the clients self-motivation
A nurse is instructing an assistive personnel (AP) about proper hand hygiene. Which of
the following statements by the AP indicates an understanding of the teaching? -
(correct answer)There are times I should use soap and water rather than an alcohol-
based hand rub to clean my hand.
A nurse is caring for an older adult client who becomes agitated when the nurse
requests that the clients dentures be removed prior to surgery. Which of the following
responses should the nurse make? - (correct answer)What worries you about being
without your teeth
, A nurse is collecting date for a client who has decreased circulation in his left leg. Which
of the following actions should the nurse take first. - (correct answer)Evaluate pedal
pulse
A nurse on a medical-surgical unit is washing her hands prior to assisting with a surgical
procedure. Which of the following actions by the nurse demonstrates proper surgical
hand-washing technique? - (correct answer)The nurse washes with her hands held
higher than her elbows
A nurse is auscultating the heart sounds of a client who has developed chest pain that
worsens with inspiration. The nurse hears a high-pitches scratching sound with the
diaphragm of the stethoscope placed at the third intercostal space of the left sternal
border. Which of the following heart sounds should the nurse document? - (correct
answer)Pericardial friction rub
A nurse is caring for a client who is unstable and has vital signs measured every 15
minutes by an electronic blood pressure machine. The nurse notices the machine
begins to measure the blood pressure at varied intervals and the reading are
inconsistent. Which of the following actions should the nurse take? - (correct
answer)Disconnect the machine and measure the blood pressure manually every 15
min
A nurse is receiving a client from the PACU who is post operative following abdominal
surgery. Which of the following actions should the nurse take to transfer the client from
the stretcher to the bed? - (correct answer)Lock the wheels on the bed and stretcher
A nurse is reinforcing preoperative teaching with a client who is scheduled for
arthroplasty in the next month and might require blood transfusion. The client expresses
concern about the risk of acquiring an infection from the blood transfusion. Which of the
following suggestions should the nurse make? - (correct answer)Donate autologous
blood before the surgery
A nurse is preparing to provide tracheostomy care for a client. Which of the following
should the nurse take first? - (correct answer)Perform hand hygiene
A nurse is reinforcing teaching of postoperative deep breathing and coughing exercises
with a client who will have emergency surgery for appendicitis. Which of the following
statements indicates a lack of readiness to learn by the client? - (correct answer)The
client reports severe pain
A nurse is caring for a client who has a terminal illness. The client asks several
questions about the nurses religious beliefs related to death and dying. Which of the
following actions should the nurse take? - (correct answer)Encourage the client to
express his thoughts about death and dying.
A nurse is measuring vital signs for a client and notices an irregularity in the pulse.
Which of the following actions should the nurse take? - (correct answer)Count the apical
pulse rate for 1 full minute, and describe the rhythm in the chart.
A nurse on a medical-surgical unit is caring for a client. Which of the following actions
should the nurse take first when using the nursing process. - (correct answer)Obtain
client information
A nurse is planning weight loss strategies for a group of clients who are obese. Which of
the following actions by the nurse will improve the clients commitment to a long-term
goal of weight loss. - (correct answer)Attempt to increase the clients self-motivation
A nurse is instructing an assistive personnel (AP) about proper hand hygiene. Which of
the following statements by the AP indicates an understanding of the teaching? -
(correct answer)There are times I should use soap and water rather than an alcohol-
based hand rub to clean my hand.
A nurse is caring for an older adult client who becomes agitated when the nurse
requests that the clients dentures be removed prior to surgery. Which of the following
responses should the nurse make? - (correct answer)What worries you about being
without your teeth
, A nurse is collecting date for a client who has decreased circulation in his left leg. Which
of the following actions should the nurse take first. - (correct answer)Evaluate pedal
pulse
A nurse on a medical-surgical unit is washing her hands prior to assisting with a surgical
procedure. Which of the following actions by the nurse demonstrates proper surgical
hand-washing technique? - (correct answer)The nurse washes with her hands held
higher than her elbows
A nurse is auscultating the heart sounds of a client who has developed chest pain that
worsens with inspiration. The nurse hears a high-pitches scratching sound with the
diaphragm of the stethoscope placed at the third intercostal space of the left sternal
border. Which of the following heart sounds should the nurse document? - (correct
answer)Pericardial friction rub
A nurse is caring for a client who is unstable and has vital signs measured every 15
minutes by an electronic blood pressure machine. The nurse notices the machine
begins to measure the blood pressure at varied intervals and the reading are
inconsistent. Which of the following actions should the nurse take? - (correct
answer)Disconnect the machine and measure the blood pressure manually every 15
min
A nurse is receiving a client from the PACU who is post operative following abdominal
surgery. Which of the following actions should the nurse take to transfer the client from
the stretcher to the bed? - (correct answer)Lock the wheels on the bed and stretcher
A nurse is reinforcing preoperative teaching with a client who is scheduled for
arthroplasty in the next month and might require blood transfusion. The client expresses
concern about the risk of acquiring an infection from the blood transfusion. Which of the
following suggestions should the nurse make? - (correct answer)Donate autologous
blood before the surgery
A nurse is preparing to provide tracheostomy care for a client. Which of the following
should the nurse take first? - (correct answer)Perform hand hygiene
