Nursing Fundamental Skills Exam Practice Questions & Correctly Detailed Answers With Rationale Updated Solution
Nursing Fundamental Skills Exam Practice
Questions & Correctly Detailed Answers With
Rationale Updated Solution
1. Which safety measure(s) should be included in the plan of care for a client with an internal
radiation implant. Select all that apply.
1. Wear a lead shield when in the client's room
2. Place the client in a room with a cohort client
3. Limit the time with the client to 1 hour per shift
4. Wear a dosimeter badge when entering the client's room
5. Save bed linens and any dressings until the implant is removed - ✔✔✔ - 1. Answer: 1, 4, 5
Rationale: The nurse should wear a lead shield when in the client's room to protect self from the
radiation that may be emitted from the implant. Additionally a dosimeter badge is worn to measure
the amount of radiation exposure. Bed linens and dressings removed from the client are saved in case
the implant was accidentally dislodged and this event was not discovered until the time when the
health care provider attempts to remove it (linens and dressings may need to be checked). The client
needs to be placed in a private room. The time that the nurse spends in a room of a client with an
internal radiation implant is 30 minutes per 8-hour shift. • Test-Taking Strategy: Focus on the subject,
care to the client with an internal radiation implant. Use principles of time, distance, and shielding.
Think about the potential exposure to radiation that can occur to assist in answering correctly. •
Review: interventions for the client with an internal radiation implant.
2. An adolescent client with a surgically wired jaw has a prescription for a full liquid diet. The nurse
should implement which action to promote the client's compliance with this diet prescription?
1. Offer chocolate milkshakes between meals
2. Explain to the adolescent the importance of good nutrition
3. Offer commercial nutritional supplements 4 to 6 times per day
4. Ask about food preferences and blenderize these foods into liquids - ✔✔✔ - 2. Answer: 4
Rationale: An adolescent may dislike a diet that is only liquids and may be at risk for noncompliance.
Thus, it is important to have the client participate in as much decision making in the diet as possible.
While blenderized foods may be unappealing under many circumstances, the nutrient value is
unchanged. The client will be able to ingest the same foods eaten prior to the jaw fracture. The
chocolate milkshakes may increase intake, but decreases the nutrient value. Adolescents may or may
not respond to reasoning and explanations. The commercial nutritional supplements may be
beneficial, but they are costly and may not be appealing to the client's taste. • Test-Taking Strategy:
Focus on the subject, and use theories of growth and development to answer this question.
, Nursing Fundamental Skills Exam Practice Questions & Correctly Detailed Answers With Rationale Updated Solution
Remember that an adolescent is generally more compliant with a difficult regimen when there is
some ability to make choices. • Review: dietary guidelines for the client following jaw surgery.
3. The nurse determines that the client understands the elements of follow-up care after a bone scan
if the client states that he or she should perform which action( s)? Select all that apply.
1. Resume the usual diet
2. Ambulate at least three times before the end of the day
3. Drink plenty of water for a day or two following the procedure
4. Report any feelings of nausea or flushing to the health care provider
5. Remain isolated in a room for 24 hours to prevent exposure of the radioisotope materials to others
- ✔✔✔ - 3. Answer: 1, 3
Rationale: There are no special restrictions after a bone scan. The client can resume the usual diet.
There are no specific activity guidelines. The client is encouraged to drink large amounts of water for
24 to 48 hours to flush the radioisotope from the system. Nausea and flushing could accompany dye
injection during a procedure, but this procedure uses radioisotopes, not dye. There are no hazards to
the client or others from the minimal amount of radioactivity of the isotope. • Test-Taking Strategy:
Note the subject, follow-up after a bone scan. Think about the procedure for a bone scan and note
that the question relates to care after the procedure. Remember, the client can resume the usual diet
and fluids to hasten elimination of the isotope from the client's system. • Review: client instructions
after bone scan.
4. The nurse prepares to bathe and change the bed linens of a client with localized herpes zoster. The
lesions are open and draining a scant amount of serous fluid. Which precaution should the nurse
ensure is followed by all health care workers?
1. Contact
2. Droplet
3. Airborne
4. Standard - ✔✔✔ - 4. Answer: 1
Rationale: The client with localized herpes zoster who has lesions that are open and draining should
be isolated and placed on contact precautions to prevent the spread of infection to others. This
communicable disease is not transmitted through air or droplets, unless it has become disseminated;
therefore options 2 and 3 are incorrect. This client requires additional transmission-based
precautions; therefore option 4 is insufficient. • Test-Taking Strategy: Note the subject, and that the
client in this question has lesions that are open and draining. In addition, recall how this disease is
transmitted to direct you to the correct option. • Review: transmission-based precautions.
5. The nurse finds an infant unconscious and suspects a foreign-body airway obstruction (FBAO). The
nurse plans to relieve the obstruction by performing which action?
, Nursing Fundamental Skills Exam Practice Questions & Correctly Detailed Answers With Rationale Updated Solution
1. Attempting ventilation
2. Performing blind finger sweeps
3. Performing a head-tilt chin-lift technique
4. Delivering five back slaps and five chest thrusts - ✔✔✔ - 5. Answer: 4
Rationale: In order to relieve FBAO in an unconscious infant, the nurse should deliver five back slaps
and five chest thrusts and repeat the sequence as necessary. Attempting ventilation will not relieve
an obstruction. The nurse should never perform blind finger sweeps because the object can be
pushed further down. The head-tilt chin-lift technique does not relieve the obstruction. • Test-Taking
Strategy: Focus on the subject, relief of a FBAO. Note that options 1, 2, and 3 are comparable or alike
and do not specifically address the subject of relieving an obstruction. • Review: nursing measures
for foreign-body airway obstruction (FBAO).
6. The nurse is preparing to assist a client who is able to transfer with two assistants from the bed to
the chair. The nurse requests assistance from staff members, but no staff members are able to help
at this time. Which action by the nurse is most appropriate at this time?
1. Ask the client's family member to assist with the transfer
2. Assist the client to transfer with the aid of the nurse and a walker
3. Use a mechanical lift to transfer the client from the bed to the chair
4. Inform the client that it is necessary to wait until someone can assist - ✔✔✔ - 6. Answer: 3
Rationale: The client who requires two assistants for transfer should never be transferred without
the aid of any less than two people, unless mechanical aids are used. The safest action by the nurse
at this time is to use a mechanical lift to transfer the client from the bed to the chair. Asking the client's
family member to assist is inappropriate and potentially unsafe. Assisting the client to transfer with
the aid of the nurse and a walker is also a potentially unsafe action, especially if the client is not
instructed in proper use of a walker. Informing the client that it is necessary to wait is not the best of
the options presented. • Test-Taking Strategy: Note the strategic words "most appropriate." Keeping
in mind client safety and determining which action would ensure safety will direct you to the correct
option. • Review: ergonomic principles.
7. Which client is at greatest risk for fluid volume deficit?
1. The client on diuretic therapy
2. The client on fertility medications
3. The client on corticosteroid therapy
4. The client on antiseizure medications - ✔✔✔ - 7. Answer: 1
Rationale: The client on diuretic therapy is at risk for fluid volume deficit due to increased fluid loss
through diuresis. Clients on fertility medications, corticosteroid therapy, and antiseizure medications
are not at risk for this disorder. • Test-Taking Strategy: Note the subject, fluid volume deficit. Note
, Nursing Fundamental Skills Exam Practice Questions & Correctly Detailed Answers With Rationale Updated Solution
that options 2, 3, and 4 are comparable or alike because they are unrelated to fluid balance in the
body. • Review: fluid volume deficit.
8. The nurse should take which action to accurately determine the length of a nasogastric tube for
insertion in an adult client?
1. Place the tube at the tip of the nose and measure by extending the tube to the umbilicus
2. Place the tube at the tip of the nose and measure by extending the tube midway between the
umbilicus and symphysis pubis
3. Place the tube at the tip of the nose and measure by extending the tube to the earlobe and then
down to the xiphoid process
4. Place the tube at the tip of the nose and measure by extending the tube to the earlobe and then
down to the top of the sternum - ✔✔✔ - 8. Answer: 3
Rationale: Measuring the length of tube needed is done by placing the tube at the tip of the client's
nose and extending the tube to the earlobe and then down to the xiphoid process. The average length
for an adult is about 22 to 26 inches. Options 1, 2, and 4 are inaccurate methods of measurement. •
Test-Taking Strategy: Note the subject, insertion of a nasogastric tube. Visualize this procedure.
Remember the acronym NEX (which stands for nose, earlobe, xiphoid process) to assist in answering
questions similar to this one. • Review: nasogastric tube insertion procedures.
9. The nurse auscultates bowel sounds and suspects an intestinal obstruction in a client with a bowel
tumor if which is heard?
1. Resonance
2. Diminished sounds
3. High-pitched sounds
4. Absent bowel sounds in all four quadrants - ✔✔✔ - 9. Answer: 3
Rationale: High-pitched tinkling sounds are indicative of an intestinal obstruction. Absent or
diminished sounds may be indicative of a paralytic ileus. Resonance is not a finding of auscultation. •
Test-Taking Strategy: Eliminate options 2 and 4 first because they are comparable or alike. Next,
focus on the subject, the assessment findings in an intestinal obstruction. This will direct you to the
correct option. • Review: bowel sounds.
10. The nursing instructor is observing a nursing student transfer a client from the bed to the chair.
The instructor intervenes if the student is observed performing which action?
1. Keeping the back, neck, pelvis, and feet aligned
2. Flexing the knees and keeping the feet wide apart
3. Encouraging the client to assist as much as possible
4. Positioning self as far away from the client as possible - ✔✔✔ - 10. Answer: 4
Nursing Fundamental Skills Exam Practice
Questions & Correctly Detailed Answers With
Rationale Updated Solution
1. Which safety measure(s) should be included in the plan of care for a client with an internal
radiation implant. Select all that apply.
1. Wear a lead shield when in the client's room
2. Place the client in a room with a cohort client
3. Limit the time with the client to 1 hour per shift
4. Wear a dosimeter badge when entering the client's room
5. Save bed linens and any dressings until the implant is removed - ✔✔✔ - 1. Answer: 1, 4, 5
Rationale: The nurse should wear a lead shield when in the client's room to protect self from the
radiation that may be emitted from the implant. Additionally a dosimeter badge is worn to measure
the amount of radiation exposure. Bed linens and dressings removed from the client are saved in case
the implant was accidentally dislodged and this event was not discovered until the time when the
health care provider attempts to remove it (linens and dressings may need to be checked). The client
needs to be placed in a private room. The time that the nurse spends in a room of a client with an
internal radiation implant is 30 minutes per 8-hour shift. • Test-Taking Strategy: Focus on the subject,
care to the client with an internal radiation implant. Use principles of time, distance, and shielding.
Think about the potential exposure to radiation that can occur to assist in answering correctly. •
Review: interventions for the client with an internal radiation implant.
2. An adolescent client with a surgically wired jaw has a prescription for a full liquid diet. The nurse
should implement which action to promote the client's compliance with this diet prescription?
1. Offer chocolate milkshakes between meals
2. Explain to the adolescent the importance of good nutrition
3. Offer commercial nutritional supplements 4 to 6 times per day
4. Ask about food preferences and blenderize these foods into liquids - ✔✔✔ - 2. Answer: 4
Rationale: An adolescent may dislike a diet that is only liquids and may be at risk for noncompliance.
Thus, it is important to have the client participate in as much decision making in the diet as possible.
While blenderized foods may be unappealing under many circumstances, the nutrient value is
unchanged. The client will be able to ingest the same foods eaten prior to the jaw fracture. The
chocolate milkshakes may increase intake, but decreases the nutrient value. Adolescents may or may
not respond to reasoning and explanations. The commercial nutritional supplements may be
beneficial, but they are costly and may not be appealing to the client's taste. • Test-Taking Strategy:
Focus on the subject, and use theories of growth and development to answer this question.
, Nursing Fundamental Skills Exam Practice Questions & Correctly Detailed Answers With Rationale Updated Solution
Remember that an adolescent is generally more compliant with a difficult regimen when there is
some ability to make choices. • Review: dietary guidelines for the client following jaw surgery.
3. The nurse determines that the client understands the elements of follow-up care after a bone scan
if the client states that he or she should perform which action( s)? Select all that apply.
1. Resume the usual diet
2. Ambulate at least three times before the end of the day
3. Drink plenty of water for a day or two following the procedure
4. Report any feelings of nausea or flushing to the health care provider
5. Remain isolated in a room for 24 hours to prevent exposure of the radioisotope materials to others
- ✔✔✔ - 3. Answer: 1, 3
Rationale: There are no special restrictions after a bone scan. The client can resume the usual diet.
There are no specific activity guidelines. The client is encouraged to drink large amounts of water for
24 to 48 hours to flush the radioisotope from the system. Nausea and flushing could accompany dye
injection during a procedure, but this procedure uses radioisotopes, not dye. There are no hazards to
the client or others from the minimal amount of radioactivity of the isotope. • Test-Taking Strategy:
Note the subject, follow-up after a bone scan. Think about the procedure for a bone scan and note
that the question relates to care after the procedure. Remember, the client can resume the usual diet
and fluids to hasten elimination of the isotope from the client's system. • Review: client instructions
after bone scan.
4. The nurse prepares to bathe and change the bed linens of a client with localized herpes zoster. The
lesions are open and draining a scant amount of serous fluid. Which precaution should the nurse
ensure is followed by all health care workers?
1. Contact
2. Droplet
3. Airborne
4. Standard - ✔✔✔ - 4. Answer: 1
Rationale: The client with localized herpes zoster who has lesions that are open and draining should
be isolated and placed on contact precautions to prevent the spread of infection to others. This
communicable disease is not transmitted through air or droplets, unless it has become disseminated;
therefore options 2 and 3 are incorrect. This client requires additional transmission-based
precautions; therefore option 4 is insufficient. • Test-Taking Strategy: Note the subject, and that the
client in this question has lesions that are open and draining. In addition, recall how this disease is
transmitted to direct you to the correct option. • Review: transmission-based precautions.
5. The nurse finds an infant unconscious and suspects a foreign-body airway obstruction (FBAO). The
nurse plans to relieve the obstruction by performing which action?
, Nursing Fundamental Skills Exam Practice Questions & Correctly Detailed Answers With Rationale Updated Solution
1. Attempting ventilation
2. Performing blind finger sweeps
3. Performing a head-tilt chin-lift technique
4. Delivering five back slaps and five chest thrusts - ✔✔✔ - 5. Answer: 4
Rationale: In order to relieve FBAO in an unconscious infant, the nurse should deliver five back slaps
and five chest thrusts and repeat the sequence as necessary. Attempting ventilation will not relieve
an obstruction. The nurse should never perform blind finger sweeps because the object can be
pushed further down. The head-tilt chin-lift technique does not relieve the obstruction. • Test-Taking
Strategy: Focus on the subject, relief of a FBAO. Note that options 1, 2, and 3 are comparable or alike
and do not specifically address the subject of relieving an obstruction. • Review: nursing measures
for foreign-body airway obstruction (FBAO).
6. The nurse is preparing to assist a client who is able to transfer with two assistants from the bed to
the chair. The nurse requests assistance from staff members, but no staff members are able to help
at this time. Which action by the nurse is most appropriate at this time?
1. Ask the client's family member to assist with the transfer
2. Assist the client to transfer with the aid of the nurse and a walker
3. Use a mechanical lift to transfer the client from the bed to the chair
4. Inform the client that it is necessary to wait until someone can assist - ✔✔✔ - 6. Answer: 3
Rationale: The client who requires two assistants for transfer should never be transferred without
the aid of any less than two people, unless mechanical aids are used. The safest action by the nurse
at this time is to use a mechanical lift to transfer the client from the bed to the chair. Asking the client's
family member to assist is inappropriate and potentially unsafe. Assisting the client to transfer with
the aid of the nurse and a walker is also a potentially unsafe action, especially if the client is not
instructed in proper use of a walker. Informing the client that it is necessary to wait is not the best of
the options presented. • Test-Taking Strategy: Note the strategic words "most appropriate." Keeping
in mind client safety and determining which action would ensure safety will direct you to the correct
option. • Review: ergonomic principles.
7. Which client is at greatest risk for fluid volume deficit?
1. The client on diuretic therapy
2. The client on fertility medications
3. The client on corticosteroid therapy
4. The client on antiseizure medications - ✔✔✔ - 7. Answer: 1
Rationale: The client on diuretic therapy is at risk for fluid volume deficit due to increased fluid loss
through diuresis. Clients on fertility medications, corticosteroid therapy, and antiseizure medications
are not at risk for this disorder. • Test-Taking Strategy: Note the subject, fluid volume deficit. Note
, Nursing Fundamental Skills Exam Practice Questions & Correctly Detailed Answers With Rationale Updated Solution
that options 2, 3, and 4 are comparable or alike because they are unrelated to fluid balance in the
body. • Review: fluid volume deficit.
8. The nurse should take which action to accurately determine the length of a nasogastric tube for
insertion in an adult client?
1. Place the tube at the tip of the nose and measure by extending the tube to the umbilicus
2. Place the tube at the tip of the nose and measure by extending the tube midway between the
umbilicus and symphysis pubis
3. Place the tube at the tip of the nose and measure by extending the tube to the earlobe and then
down to the xiphoid process
4. Place the tube at the tip of the nose and measure by extending the tube to the earlobe and then
down to the top of the sternum - ✔✔✔ - 8. Answer: 3
Rationale: Measuring the length of tube needed is done by placing the tube at the tip of the client's
nose and extending the tube to the earlobe and then down to the xiphoid process. The average length
for an adult is about 22 to 26 inches. Options 1, 2, and 4 are inaccurate methods of measurement. •
Test-Taking Strategy: Note the subject, insertion of a nasogastric tube. Visualize this procedure.
Remember the acronym NEX (which stands for nose, earlobe, xiphoid process) to assist in answering
questions similar to this one. • Review: nasogastric tube insertion procedures.
9. The nurse auscultates bowel sounds and suspects an intestinal obstruction in a client with a bowel
tumor if which is heard?
1. Resonance
2. Diminished sounds
3. High-pitched sounds
4. Absent bowel sounds in all four quadrants - ✔✔✔ - 9. Answer: 3
Rationale: High-pitched tinkling sounds are indicative of an intestinal obstruction. Absent or
diminished sounds may be indicative of a paralytic ileus. Resonance is not a finding of auscultation. •
Test-Taking Strategy: Eliminate options 2 and 4 first because they are comparable or alike. Next,
focus on the subject, the assessment findings in an intestinal obstruction. This will direct you to the
correct option. • Review: bowel sounds.
10. The nursing instructor is observing a nursing student transfer a client from the bed to the chair.
The instructor intervenes if the student is observed performing which action?
1. Keeping the back, neck, pelvis, and feet aligned
2. Flexing the knees and keeping the feet wide apart
3. Encouraging the client to assist as much as possible
4. Positioning self as far away from the client as possible - ✔✔✔ - 10. Answer: 4
