Fundamentals
1. A nurse is reviewing information about the Health Insurance Portability and Accountability Act (HIPAA) with a newly
licensed nurse. Which of the following statements by the newly licensed nurse indicates a need for further
teaching?
A. "Information about a client can be disclosed to family members at any time."
B. "HIPAA established regulations of individually identifiable health information in verbal, electronic, or written
form."
C. "A client's address would be an example of personally identifiable information."
D. "HIPAA is a federal law, not a state law."
2. A nurse is preparing to perform hand hygiene. Which of the following actions should the nurse take?
A. Adjust the water temperature to feel hot.
B. Apply 4 to 5 mL of liquid soap to the hands.
C. Hold the hands higher than the elbows.
D. Rub hands and arms to dry.
3. A nurse is preparing to administer three liquid medications to a client who has an NG feeding tube with continuous
enteral feedings. Which of the following actions should the nurse take?
A. Mix the three medications together prior to administering.
B. Dilute each medication with 10 mL of tap water.
C. Maintain the head of the bed in a flat position for 30 min following medication administration.
D. Flush the NG feeding tube with 30 mL of water immediately following medication administration
4. A nurse is administering nasal decongestant drops for a client. Which of the following actions should the nurse
take?
A. Tell the client to blow her nose gently before the instillation.
B. Assist the client to a side-lying position.
C. Hold the dropper 2 cm (1 in) above the naris.
D. Instruct the client to stay in the same position for 2 min.
Created on:11/24/2020 Page 1
, Fundamentals
5. A nurse is performing tracheostomy care for a client and suctioning to remove copious secretions. Which of the
following actions should the nurse take?
A. Suction two to three times with a 60-second pause between passes.
B. Perform chest physiotherapy prior to suctioning.
C. Lubricate the suction catheter tip with sterile saline.
D. Hyperventilate the client on 100% oxygen prior to suctioning.
6. A newly licensed nurse is applying prescribed wrist restraints on a client. Which of the following actions should the
nurse take?
A. Secure the restraints using a quick-release tie.
B. Ensure four fingers fit under the restraints to prevent constriction.
C. Secure the restraints to the lowest bar of the side rail.
D. Anticipate removing the restraints every 4 hr.
7. The family of an older adult client brings him to the emergency department after finding him wandering outside.
During the initial assessment, the nurse notes that the client flinches when she palpates his abdomen yet responds
to questions only by nodding and smiling. Which of the following factors should the nurse identify as a likely
explanation for the client's behavior?
A. He is hard of hearing.
B. Pain
C. Confusion
D. Language barrier
8. A nurse is preparing a client for outpatient surgery. After the nurse inserts the IV catheter, the client reports pain in
the insertion area. Which of the following actions should the nurse take?
A. Remove the catheter and insert another into a different site.
B. Administer an analgesic PO.
C. Request a prescription for placement of a central venous access device.
D. Administer a local anesthetic.
Created on:11/24/2020 Page 2
, Fundamentals
9. A client smoking in his bathroom has dropped a cigarette butt into a wastepaper basket, which begins to smolder.
Which of the following actions is the nurse’s priority?
A. Close the fire doors on the unit.
B. Activate the fire alarm.
C. Move any clients in the immediate vicinity.
D. Use a fire extinguisher to put out the fire.
10. A nurse is caring for a client who refuses treatment and asks to be discharged from the hospital against medical
advice. The nurse notifies the client's provider, who tells the nurse to restrain the client, if necessary, to keep her
from leaving the hospital. The nurse understands that restraining this client would be considered which type of civil
action by the nurse?
A. Invasion of privacy
B. Assault
C. Battery
D. False imprisonment
11. A nurse is inserting an IV catheter for an older client in preparation for an outpatient procedure. Which of the
following veins should the nurse select?
A. Dorsal metacarpal vein
B. Radial vein in the wrist
C. Antecubital vein
D. Median vein in the forearm
12. A nurse is providing oral care for a client who is immobile. Which of the following actions should the nurse take?
A. Use a stiff toothbrush to clean the client's teeth.
B. Use the thumb and index finger to keep the client's mouth open.
C. Turn the client on his side before starting oral care.
D. Apply petroleum jelly to the client's lips after oral care.
Created on:11/24/2020 Page 3
1. A nurse is reviewing information about the Health Insurance Portability and Accountability Act (HIPAA) with a newly
licensed nurse. Which of the following statements by the newly licensed nurse indicates a need for further
teaching?
A. "Information about a client can be disclosed to family members at any time."
B. "HIPAA established regulations of individually identifiable health information in verbal, electronic, or written
form."
C. "A client's address would be an example of personally identifiable information."
D. "HIPAA is a federal law, not a state law."
2. A nurse is preparing to perform hand hygiene. Which of the following actions should the nurse take?
A. Adjust the water temperature to feel hot.
B. Apply 4 to 5 mL of liquid soap to the hands.
C. Hold the hands higher than the elbows.
D. Rub hands and arms to dry.
3. A nurse is preparing to administer three liquid medications to a client who has an NG feeding tube with continuous
enteral feedings. Which of the following actions should the nurse take?
A. Mix the three medications together prior to administering.
B. Dilute each medication with 10 mL of tap water.
C. Maintain the head of the bed in a flat position for 30 min following medication administration.
D. Flush the NG feeding tube with 30 mL of water immediately following medication administration
4. A nurse is administering nasal decongestant drops for a client. Which of the following actions should the nurse
take?
A. Tell the client to blow her nose gently before the instillation.
B. Assist the client to a side-lying position.
C. Hold the dropper 2 cm (1 in) above the naris.
D. Instruct the client to stay in the same position for 2 min.
Created on:11/24/2020 Page 1
, Fundamentals
5. A nurse is performing tracheostomy care for a client and suctioning to remove copious secretions. Which of the
following actions should the nurse take?
A. Suction two to three times with a 60-second pause between passes.
B. Perform chest physiotherapy prior to suctioning.
C. Lubricate the suction catheter tip with sterile saline.
D. Hyperventilate the client on 100% oxygen prior to suctioning.
6. A newly licensed nurse is applying prescribed wrist restraints on a client. Which of the following actions should the
nurse take?
A. Secure the restraints using a quick-release tie.
B. Ensure four fingers fit under the restraints to prevent constriction.
C. Secure the restraints to the lowest bar of the side rail.
D. Anticipate removing the restraints every 4 hr.
7. The family of an older adult client brings him to the emergency department after finding him wandering outside.
During the initial assessment, the nurse notes that the client flinches when she palpates his abdomen yet responds
to questions only by nodding and smiling. Which of the following factors should the nurse identify as a likely
explanation for the client's behavior?
A. He is hard of hearing.
B. Pain
C. Confusion
D. Language barrier
8. A nurse is preparing a client for outpatient surgery. After the nurse inserts the IV catheter, the client reports pain in
the insertion area. Which of the following actions should the nurse take?
A. Remove the catheter and insert another into a different site.
B. Administer an analgesic PO.
C. Request a prescription for placement of a central venous access device.
D. Administer a local anesthetic.
Created on:11/24/2020 Page 2
, Fundamentals
9. A client smoking in his bathroom has dropped a cigarette butt into a wastepaper basket, which begins to smolder.
Which of the following actions is the nurse’s priority?
A. Close the fire doors on the unit.
B. Activate the fire alarm.
C. Move any clients in the immediate vicinity.
D. Use a fire extinguisher to put out the fire.
10. A nurse is caring for a client who refuses treatment and asks to be discharged from the hospital against medical
advice. The nurse notifies the client's provider, who tells the nurse to restrain the client, if necessary, to keep her
from leaving the hospital. The nurse understands that restraining this client would be considered which type of civil
action by the nurse?
A. Invasion of privacy
B. Assault
C. Battery
D. False imprisonment
11. A nurse is inserting an IV catheter for an older client in preparation for an outpatient procedure. Which of the
following veins should the nurse select?
A. Dorsal metacarpal vein
B. Radial vein in the wrist
C. Antecubital vein
D. Median vein in the forearm
12. A nurse is providing oral care for a client who is immobile. Which of the following actions should the nurse take?
A. Use a stiff toothbrush to clean the client's teeth.
B. Use the thumb and index finger to keep the client's mouth open.
C. Turn the client on his side before starting oral care.
D. Apply petroleum jelly to the client's lips after oral care.
Created on:11/24/2020 Page 3
