REGISTERED (RN)
FUNDAMENTALS FINAL (124)EXAM
QUESTIONS AND VERIFIED
ANSWERS WITH RATIOANLES -
GRADED A+
1. The postoperative client is placed on a clear liquid diet. Which selections will the nurse select for the
client? (Select all that apply.)
A. Apple juice
B. Popsicles
C. Vanilla pudding
D. Tomato soup
E. Gelatin
F. Black coffee
Answers A, B, E, F
Rationale: Clear liquids are transparent and liquid at room temperature. Tomato soup and vanilla
pudding are included in a full liquid diet
2. The nurse is providing care to clients at a day treatment center. One of the clients who is usually
talkative and eats well is now confused and did not eat lunch. The nurse learns these are new
findings as of today. What are the next nursing actions? (Select all that apply.)
A. Obtain a clean catch urine sample.
B. Take the client's vital signs.
C. Assess for the initiation of any new medications.
D. Obtain an oxygen saturation.
E. Call the client's children to report the confusion.
F. Call the facility's bus service to return the client home.
Answers A, B, C, D
,Rationale: Until the assessment is complete, there is no need to contact the client's children. With the
client's state of confusion, the nurse cannot dismiss the client to home. The client is exhibiting signs of
an infection with the confusion and anorexia. The remaining assessments will help the nurse determine
if the client has an infection or if there is another reason for the confusion.
3. The nurse is providing care to an 86-year-old admitted for a heart catheterization. The nurse
determines the client does not have an advance directive (AD) on file. What are the nurse's next
steps? (Select all that apply.)
A. Ask the client's cardiologist to come to the hospital and obtain the AD.
B. Ask the client, "Have you considered completing the paperwork for an AD?"
C. Ask the client's spouse to complete the AD.
D. Tell the client, "An AD helps the staff provide care according to your wishes."
E. Call the client's clergy member to make the final decisions for the client.
Answers B, D
Rationale: A living will is one type of advance directive. The living will outlines the medical treatment the
client elects in the event that the client is no longer able to participate in the decision-making process.
As long as the client has capacity, the client is the sole determinant for the AD. While a living will
describes the wishes of the client, it does not have to be obtained from the physician. Clients may be
assisted by the social work staff. The forms can be completed outside of a medical facility and it is the
client's responsibility to provide a copy of the AD to all health care providers.
4. In completing a client's preoperative routine, the nurse finds that the operative permit is not signed.
The client begins to ask more questions about the surgical procedure. Which action should the nurse
take next?
A. Witness the client's signature to the permit.
B. Answer the client's questions about the surgery.
C. Inform the surgeon the client has questions about the surgery.
D. Reassure the client that the surgeon will answer any questions before the anesthesia is
administered.
Answer C
Rationale: It is the surgeon's responsibility to explain the procedure to the client and obtain the client's
signature on the permit. Although the nurse can witness an operative permit, the procedure must first
be explained by the health care provider or surgeon, including answering the client's questions. The
client's questions should be addressed before the permit is signed.
,5. A client becomes angry while waiting for a supervised break to smoke a cigarette outside and states,
"I want to go outside now and smoke. It takes forever to get anything done here!" Which nursing
action is best for this client?
A. Encourage the client to use a nicotine patch.
B. Reassure the client that it is almost time for another break.
C. Have the client leave the unit with another staff member.
D. Review the schedule of outdoor breaks with the client.
Answer D
Rationale: The best nursing action is to review the schedule of outdoor breaks and provide concrete
information about the schedule. Option A is contraindicated if the client wants to continue smoking.
Option B is insufficient to encourage a trusting relationship with the client. Option C is preferential for
this client only and is inconsistent with unit rules.
6. During a routine assessment, an obese 50-year-old client states, "I feel so unlovable because of my
weight." Which is the best response by the nurse?
A. Reassure the client that many obese people have concerns about sex.
B. Remind the client that sexual relationships need not be affected by obesity.
C. Determine the frequency of sexual intercourse.
D. Ask the client to talk about specific concerns.
Answer D
Rationale: Option D provides an opportunity for the client to verbalize concerns and provides the nurse
with more assessment data. Options A and B may not be related to the current concern, assume that
obesity is the problem, and are communication blocks. Option C may be appropriate after discussing the
stated concerns.
7. The clinic nurse is conducting an assessment of a 2-year-old. The nurse asks the mother, "What is
your child playing with now?" Which response indicates to the nurse that further teaching is
needed? (Select all that apply.)
A. "We color together using jumbo crayons."
B. "Finger paints in the kitchen are a favorite pastime."
C. "A marble run race track is set up in the playroom."
D. "When outside, the wagon filled with soccer balls is the preferred toy."
E. "We got a golf set because my other children play golf."
Answers C, E
, Rationale: Avoid small objects that can be a choking hazard during the toddler stage. The remaining play
toys are appropriate for toddlers.
8. The nurse is orienting a new graduate to the reporting regulations often seen in the emergency
department. Which clients will the nurse need to report to the nurse manager/supervisor to alert
the proper authorities? (Select all that apply.)
A. A 7-year-old who states, "I get beat up by my parents all the time." The child has bruising on the
back in various stages of healing.
B. An 88-year-old who states, "My child lives 5 minutes away no longer stops to visit. My days are
long and lonely."
C. A 40-year-old who states, "I was in an argument with my sibling and the next thing I knew I was
shot in the shoulder."
D. An 18-year-old who states, "Once I turned 18 my parents demanded I leave their home. I was no
longer welcomed there."
E. A 30-year-old who states, "The brawl was worth the stab wound I got. My family has never liked
that family. It is just that way."
Answers A, C, E
Rationale: Nurses are mandatory reporters and must notify in the event of child and elder abuse,
domestic violence, animal bites, gun shot and stab wounds, assault, and homicides
9. In the middle of running a resuscitation for a cardiac arrest the LPN states to the nurse, "What can I
do for your other patients?" The nurse says to the LPN, "Go ahead and start that blood on the client
in 434B. It is primed and ready to go. You have seen me do it a million times. You can do it." What is
the LPN's best response?
A. "No way am I starting the blood on that client!"
B. "I am going to tell the manager you asked me to start blood."
C. "Sure, no problem. I can do that. I have done it before."
D. "I can take over compressions so you can start the blood."
Answer D
Rationale: The LPN needs to remain professional, and stating "No way ...." is an unprofessional response.
Telling the manager may be appropriate, but it does nothing to help the situation of needing to start
blood and resuscitate a client. Blood administration is the responsibility of the RN. The LPN can perform
compressions.
FUNDAMENTALS FINAL (124)EXAM
QUESTIONS AND VERIFIED
ANSWERS WITH RATIOANLES -
GRADED A+
1. The postoperative client is placed on a clear liquid diet. Which selections will the nurse select for the
client? (Select all that apply.)
A. Apple juice
B. Popsicles
C. Vanilla pudding
D. Tomato soup
E. Gelatin
F. Black coffee
Answers A, B, E, F
Rationale: Clear liquids are transparent and liquid at room temperature. Tomato soup and vanilla
pudding are included in a full liquid diet
2. The nurse is providing care to clients at a day treatment center. One of the clients who is usually
talkative and eats well is now confused and did not eat lunch. The nurse learns these are new
findings as of today. What are the next nursing actions? (Select all that apply.)
A. Obtain a clean catch urine sample.
B. Take the client's vital signs.
C. Assess for the initiation of any new medications.
D. Obtain an oxygen saturation.
E. Call the client's children to report the confusion.
F. Call the facility's bus service to return the client home.
Answers A, B, C, D
,Rationale: Until the assessment is complete, there is no need to contact the client's children. With the
client's state of confusion, the nurse cannot dismiss the client to home. The client is exhibiting signs of
an infection with the confusion and anorexia. The remaining assessments will help the nurse determine
if the client has an infection or if there is another reason for the confusion.
3. The nurse is providing care to an 86-year-old admitted for a heart catheterization. The nurse
determines the client does not have an advance directive (AD) on file. What are the nurse's next
steps? (Select all that apply.)
A. Ask the client's cardiologist to come to the hospital and obtain the AD.
B. Ask the client, "Have you considered completing the paperwork for an AD?"
C. Ask the client's spouse to complete the AD.
D. Tell the client, "An AD helps the staff provide care according to your wishes."
E. Call the client's clergy member to make the final decisions for the client.
Answers B, D
Rationale: A living will is one type of advance directive. The living will outlines the medical treatment the
client elects in the event that the client is no longer able to participate in the decision-making process.
As long as the client has capacity, the client is the sole determinant for the AD. While a living will
describes the wishes of the client, it does not have to be obtained from the physician. Clients may be
assisted by the social work staff. The forms can be completed outside of a medical facility and it is the
client's responsibility to provide a copy of the AD to all health care providers.
4. In completing a client's preoperative routine, the nurse finds that the operative permit is not signed.
The client begins to ask more questions about the surgical procedure. Which action should the nurse
take next?
A. Witness the client's signature to the permit.
B. Answer the client's questions about the surgery.
C. Inform the surgeon the client has questions about the surgery.
D. Reassure the client that the surgeon will answer any questions before the anesthesia is
administered.
Answer C
Rationale: It is the surgeon's responsibility to explain the procedure to the client and obtain the client's
signature on the permit. Although the nurse can witness an operative permit, the procedure must first
be explained by the health care provider or surgeon, including answering the client's questions. The
client's questions should be addressed before the permit is signed.
,5. A client becomes angry while waiting for a supervised break to smoke a cigarette outside and states,
"I want to go outside now and smoke. It takes forever to get anything done here!" Which nursing
action is best for this client?
A. Encourage the client to use a nicotine patch.
B. Reassure the client that it is almost time for another break.
C. Have the client leave the unit with another staff member.
D. Review the schedule of outdoor breaks with the client.
Answer D
Rationale: The best nursing action is to review the schedule of outdoor breaks and provide concrete
information about the schedule. Option A is contraindicated if the client wants to continue smoking.
Option B is insufficient to encourage a trusting relationship with the client. Option C is preferential for
this client only and is inconsistent with unit rules.
6. During a routine assessment, an obese 50-year-old client states, "I feel so unlovable because of my
weight." Which is the best response by the nurse?
A. Reassure the client that many obese people have concerns about sex.
B. Remind the client that sexual relationships need not be affected by obesity.
C. Determine the frequency of sexual intercourse.
D. Ask the client to talk about specific concerns.
Answer D
Rationale: Option D provides an opportunity for the client to verbalize concerns and provides the nurse
with more assessment data. Options A and B may not be related to the current concern, assume that
obesity is the problem, and are communication blocks. Option C may be appropriate after discussing the
stated concerns.
7. The clinic nurse is conducting an assessment of a 2-year-old. The nurse asks the mother, "What is
your child playing with now?" Which response indicates to the nurse that further teaching is
needed? (Select all that apply.)
A. "We color together using jumbo crayons."
B. "Finger paints in the kitchen are a favorite pastime."
C. "A marble run race track is set up in the playroom."
D. "When outside, the wagon filled with soccer balls is the preferred toy."
E. "We got a golf set because my other children play golf."
Answers C, E
, Rationale: Avoid small objects that can be a choking hazard during the toddler stage. The remaining play
toys are appropriate for toddlers.
8. The nurse is orienting a new graduate to the reporting regulations often seen in the emergency
department. Which clients will the nurse need to report to the nurse manager/supervisor to alert
the proper authorities? (Select all that apply.)
A. A 7-year-old who states, "I get beat up by my parents all the time." The child has bruising on the
back in various stages of healing.
B. An 88-year-old who states, "My child lives 5 minutes away no longer stops to visit. My days are
long and lonely."
C. A 40-year-old who states, "I was in an argument with my sibling and the next thing I knew I was
shot in the shoulder."
D. An 18-year-old who states, "Once I turned 18 my parents demanded I leave their home. I was no
longer welcomed there."
E. A 30-year-old who states, "The brawl was worth the stab wound I got. My family has never liked
that family. It is just that way."
Answers A, C, E
Rationale: Nurses are mandatory reporters and must notify in the event of child and elder abuse,
domestic violence, animal bites, gun shot and stab wounds, assault, and homicides
9. In the middle of running a resuscitation for a cardiac arrest the LPN states to the nurse, "What can I
do for your other patients?" The nurse says to the LPN, "Go ahead and start that blood on the client
in 434B. It is primed and ready to go. You have seen me do it a million times. You can do it." What is
the LPN's best response?
A. "No way am I starting the blood on that client!"
B. "I am going to tell the manager you asked me to start blood."
C. "Sure, no problem. I can do that. I have done it before."
D. "I can take over compressions so you can start the blood."
Answer D
Rationale: The LPN needs to remain professional, and stating "No way ...." is an unprofessional response.
Telling the manager may be appropriate, but it does nothing to help the situation of needing to start
blood and resuscitate a client. Blood administration is the responsibility of the RN. The LPN can perform
compressions.
