Rn Fundamentals Online Practice 2023 B Latest Updated 2024
A nurse in a medical-surgical unit is caring for six clients. which 2 should she see
first?
1. rheumatoid arthritis, C-reactive protein 3.2 mg/dL
2. history of hyperlipidemia, Cholesterol 250 mg/dL
3. 1 day postoperative. Reports pain as 8 on a scale of 0 to 10, Oxygen saturation
88%
4. new diagnosis of heart failure, Potassium 3.2 mEq/L
5. stage 2 pressure injury, Prealbumin 14 mg/dL
6. new diagnosis of diabetes mellitus, Glycosylated hemoglobin 8% - ANSWER-
clients 3 & 4
Drop Down 1:
Client 1 is incorrect. The nurse should assess this client because the client's C-
reactive protein is greater than the expected reference range, which is an
indication of inflammation. However, there is another client the nurse should
assess first.
Client 2 is incorrect. The nurse should assess this client because the client's
cholesterol level is greater than the expected reference range, which places them
at risk for coronary heart disease. However, there is another client the nurse
should assess first.
,Client 3 is correct. When using the airway, breathing, circulation approach to
client care, the nurse should determine that this client is the priority client to
assess. The client has an oxygen saturation that is less than the expected
reference range, which is an indication of hypoxia.
Drop Down 2:
Client 4 is correct. When using the airway, breathing, circulation approach to
client care, the nurse should determine that this client is the next priority client to
assess. The client has a potassium level that is less than the expected reference
range, which places the client at risk for dysrhythmias.
Client 5 is incorrect. The nurse should assess this client because their prealbumin
level is less than the expected reference range, which places them at risk for
delayed wound healing. However, this client is not the next priority client to
assess.
Client 6 is incorrect. The nurse should assess this client because their
glycosylated hemoglobin level is greater than the expected reference range,
which indicates poor diabetic control. However, this client is not the next priority
client to assess.
A nurse is caring for a client who has a peripheral IV inserted for fluid
replacement.
Nurses' Notes
Day 1:
Lactated Ringer's at 100 mL/hr infusing into a 20-gauge IV catheter in left hand. IV
dressing dry and intact. IV site without redness or swelling. IV fluid infusing well.
Day 2:
,IV site edematous. Skin surrounding catheter site taut, blanched, and cool to
touch. IV fluid not infusing.
select all that apply
a. Start a new IV in the client's left hand.
b. Place a pressure dressing over the IV site.
c. Apply heat to the client's left hand.
d. Elevate the client's left arm.
e. Stop the IV infusion. - ANSWER-c, d, e
Stop the IV infusion is correct. The client has manifestations of IV infiltration. The
nurse should stop the IV infusion and remove the IV catheter to reduce the risk
for tissue damage.
Elevate the client's left arm is correct. The nurse should elevate the client's left
hand to decrease swelling and reduce the risk for tissue damage.
Apply heat to the client's left hand is correct. The nurse should apply heat to the
client's left hand to reduce swelling and promote comfort.
Place a pressure dressing over the IV site is incorrect. The nurse should not apply
pressure to the IV site, because this can cause tissue damage.
Start a new IV in the client's left hand is incorrect. The nurse should start a new IV
in a different extremity to reduce the risk of tissue damage.
A nurse is giving a change-of-shift report about a client admitted earlier that day
who has pneumonia. Which of the following pieces of information is the priority for
the nurse to provide?
, a. Admitting diagnosis
b. Breath sounds
c. Body temperature
d. Diagnostic test results - ANSWER-b
When using the airway, breathing, circulation approach to client care, the nurse
should determine that the priority information to provide is the current status of
the client's breath sounds.
A nurse is preparing to transfer a client who can bear weight on one leg from the
bed to a chair. After securing a safe environment, which of the following actions
should the nurse take next?
a. Rock the client up to a standing position.
b. Pivot on the foot that is the farthest from the chair.
c. Assess the client for orthostatic hypotension.
d. Apply a gait belt to the client. - ANSWER-c
The first action the nurse should take when using the nursing process is to assess
the client. The nurse should determine the client's risk for falling or fainting
during the transfer by assisting the client to sit and dangle the feet on the side of
the bed. The nurse should assess for dizziness and a significant drop in blood
pressure before assisting the client to stand and transfer into the chair.
A nurse in a medical-surgical unit is caring for six clients. which 2 should she see
first?
1. rheumatoid arthritis, C-reactive protein 3.2 mg/dL
2. history of hyperlipidemia, Cholesterol 250 mg/dL
3. 1 day postoperative. Reports pain as 8 on a scale of 0 to 10, Oxygen saturation
88%
4. new diagnosis of heart failure, Potassium 3.2 mEq/L
5. stage 2 pressure injury, Prealbumin 14 mg/dL
6. new diagnosis of diabetes mellitus, Glycosylated hemoglobin 8% - ANSWER-
clients 3 & 4
Drop Down 1:
Client 1 is incorrect. The nurse should assess this client because the client's C-
reactive protein is greater than the expected reference range, which is an
indication of inflammation. However, there is another client the nurse should
assess first.
Client 2 is incorrect. The nurse should assess this client because the client's
cholesterol level is greater than the expected reference range, which places them
at risk for coronary heart disease. However, there is another client the nurse
should assess first.
,Client 3 is correct. When using the airway, breathing, circulation approach to
client care, the nurse should determine that this client is the priority client to
assess. The client has an oxygen saturation that is less than the expected
reference range, which is an indication of hypoxia.
Drop Down 2:
Client 4 is correct. When using the airway, breathing, circulation approach to
client care, the nurse should determine that this client is the next priority client to
assess. The client has a potassium level that is less than the expected reference
range, which places the client at risk for dysrhythmias.
Client 5 is incorrect. The nurse should assess this client because their prealbumin
level is less than the expected reference range, which places them at risk for
delayed wound healing. However, this client is not the next priority client to
assess.
Client 6 is incorrect. The nurse should assess this client because their
glycosylated hemoglobin level is greater than the expected reference range,
which indicates poor diabetic control. However, this client is not the next priority
client to assess.
A nurse is caring for a client who has a peripheral IV inserted for fluid
replacement.
Nurses' Notes
Day 1:
Lactated Ringer's at 100 mL/hr infusing into a 20-gauge IV catheter in left hand. IV
dressing dry and intact. IV site without redness or swelling. IV fluid infusing well.
Day 2:
,IV site edematous. Skin surrounding catheter site taut, blanched, and cool to
touch. IV fluid not infusing.
select all that apply
a. Start a new IV in the client's left hand.
b. Place a pressure dressing over the IV site.
c. Apply heat to the client's left hand.
d. Elevate the client's left arm.
e. Stop the IV infusion. - ANSWER-c, d, e
Stop the IV infusion is correct. The client has manifestations of IV infiltration. The
nurse should stop the IV infusion and remove the IV catheter to reduce the risk
for tissue damage.
Elevate the client's left arm is correct. The nurse should elevate the client's left
hand to decrease swelling and reduce the risk for tissue damage.
Apply heat to the client's left hand is correct. The nurse should apply heat to the
client's left hand to reduce swelling and promote comfort.
Place a pressure dressing over the IV site is incorrect. The nurse should not apply
pressure to the IV site, because this can cause tissue damage.
Start a new IV in the client's left hand is incorrect. The nurse should start a new IV
in a different extremity to reduce the risk of tissue damage.
A nurse is giving a change-of-shift report about a client admitted earlier that day
who has pneumonia. Which of the following pieces of information is the priority for
the nurse to provide?
, a. Admitting diagnosis
b. Breath sounds
c. Body temperature
d. Diagnostic test results - ANSWER-b
When using the airway, breathing, circulation approach to client care, the nurse
should determine that the priority information to provide is the current status of
the client's breath sounds.
A nurse is preparing to transfer a client who can bear weight on one leg from the
bed to a chair. After securing a safe environment, which of the following actions
should the nurse take next?
a. Rock the client up to a standing position.
b. Pivot on the foot that is the farthest from the chair.
c. Assess the client for orthostatic hypotension.
d. Apply a gait belt to the client. - ANSWER-c
The first action the nurse should take when using the nursing process is to assess
the client. The nurse should determine the client's risk for falling or fainting
during the transfer by assisting the client to sit and dangle the feet on the side of
the bed. The nurse should assess for dizziness and a significant drop in blood
pressure before assisting the client to stand and transfer into the chair.
