1
RN Fundamentals Online Practice 2019 B
RN Fundamentals Online Practice 2019 B
1. A charge nurse is discussing the responsibility of nurses caring for clients who have a
Clostridium difficile infection. Which of the following information should the nurse
include in the teaching?
Correct Answer✅: Have family members wear a gown and gloves when visiting.
Rationale:
Nurses are responsible for ensuring that family members wear a gown and gloves to
prevent the transmission of Clostridium difficile spores. Staff must also wear gowns and
gloves.
2. A nurse is giving change-of-shift report about a client they admitted earlier that day who
has pneumonia. Which of the following pieces of information is the priority for the nurse
to provide?
Correct Answer✅: Breath sounds
Rationale: 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.
3. A nurse is preparing to delegate client care tasks to an assistive personnel (AP).
Which of the following tasks should the nurse delegate?
Correct Answer✅: Ambulating a client who is postoperative
Rationale: Ambulating a client is within the range of function of an AP. The nurse can
delegate tasks to the AP that do not require special skills, assessment, or teaching.
4. A nurse enters a client’s room and finds her on the floor. The client’s roommate reports
that the client was trying to get out of bed and fell over the side rail onto the floor.
Which of the following statements should the nurse document about this incident?
Correct Answer✅: "Client found lying on
floor."
Rationale: The nurse should include documentation of information that is
descriptive and objective concerning what the nurse actually observed, without
including any opinions or judgments about motives or cause.
5. A nurse is caring for a client who has a prescription for wound irrigation. Which of the
pg. 1
,2
RN Fundamentals Online Practice 2019 B
following actions should the nurse take?
Correct Answer✅: Cleanse the wound from the center outward.
Rationale: The nurse should clean the wound from the center outward to prevent
introduction of micro-organisms from the outer skin surface. The nurse should wear clean
gloves to remove the old dressing, not sterile gloves. The nurse should warm the
irrigation solution to body temperature.
The nurse should use a 35-mL syringe to irrigate the wound. Syringes that hold 30 to 60
mL of fluid create a safe but effective amount of pressure for wound irrigation.
6. A nurse is admitting a client who has rubella. Which of the following types of
transmission-based precautions should the nurse initiate?
Correct
Answer✅:
Droplet
Rationale: Droplet precautions are a requirement for clients who have infections that
spread via droplet nuclei that are larger than 5 microns in diameter, including influenza,
rubella, meningococcal pneumonia, and streptococcal pharyngitis. Airborne precautions
are a requirement for clients who have infections that spread via droplet nuclei that are
smaller than 5 microns in diameter, including varicella, tuberculosis, and measles.
pg. 2
, 3
RN Fundamentals Online Practice 2019 B
7. A nurse is providing discharge teaching for a client who has a new prescription for a
home oxygen concentrator. Which of the following instructions should the nurse
provide to the client and his family? (Select all that apply.)
Correct Answer✅: Check the cord routinely for frays or tearing; consider purchasing a
generator for power backup; observe for signs of hypoxia
Rationale: Oxygen concentrators require electrical power. Safe use of this delivery
system includes assessing the electrical function of the device; therefore, the nurse should
instruct the client to routinely check the condition of the cord. Loss of electricity prevents
the oxygen concentrator from functioning and could deprive the client of necessary
oxygen. The nurse should also instruct the family to have the client placed on their
municipality's priority list for restoring power after an outage occurs. The nurse should
instruct the family to observe for and report signs of hypoxia, such as anxiety, worsening
fatigue, dizziness, rapid pulse and respirations, pallor, and cyanosis. Even with
supplemental oxygen, the client's status can worsen, resulting in the development of
hypoxia.
8. A nurse is calculating a client’s fluid intake over the past 8 hr. which of the following
items should the nurse plan to document on the client’s intake and output record as 120
mL of fluid?
Correct Answer✅: 8 oz of ice chips
Rationale: The nurse should document half of the volume of ice chips when
calculating fluid intake to account for the air in between the chips. The nurse should
understand that 4 oz of liquid water is equal to 120 mL of fluid.
9. A nurse is caring for a client who has tuberculosis. Which of the following actions
should the nurse take? (Select all that apply.)
Correct Answer✅: Place the client in a room with negative-pressure airflow; wear
gloves when assisting the client with oral care; use antimicrobial sanitizer for hand
hygiene
Rationale: The nurse should place the client in a room with negative-pressure airflow to
meet the requirements of airborne precautions. The nurse should wear gloves when
assisting the client with oral care to meet the requirements of standard precautions,
which the nurse must adhere to for all clients regardless of their diagnosis. The nurse
should wear gloves whenever their hands might come in contact with a client's bodily
pg. 3
RN Fundamentals Online Practice 2019 B
RN Fundamentals Online Practice 2019 B
1. A charge nurse is discussing the responsibility of nurses caring for clients who have a
Clostridium difficile infection. Which of the following information should the nurse
include in the teaching?
Correct Answer✅: Have family members wear a gown and gloves when visiting.
Rationale:
Nurses are responsible for ensuring that family members wear a gown and gloves to
prevent the transmission of Clostridium difficile spores. Staff must also wear gowns and
gloves.
2. A nurse is giving change-of-shift report about a client they admitted earlier that day who
has pneumonia. Which of the following pieces of information is the priority for the nurse
to provide?
Correct Answer✅: Breath sounds
Rationale: 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.
3. A nurse is preparing to delegate client care tasks to an assistive personnel (AP).
Which of the following tasks should the nurse delegate?
Correct Answer✅: Ambulating a client who is postoperative
Rationale: Ambulating a client is within the range of function of an AP. The nurse can
delegate tasks to the AP that do not require special skills, assessment, or teaching.
4. A nurse enters a client’s room and finds her on the floor. The client’s roommate reports
that the client was trying to get out of bed and fell over the side rail onto the floor.
Which of the following statements should the nurse document about this incident?
Correct Answer✅: "Client found lying on
floor."
Rationale: The nurse should include documentation of information that is
descriptive and objective concerning what the nurse actually observed, without
including any opinions or judgments about motives or cause.
5. A nurse is caring for a client who has a prescription for wound irrigation. Which of the
pg. 1
,2
RN Fundamentals Online Practice 2019 B
following actions should the nurse take?
Correct Answer✅: Cleanse the wound from the center outward.
Rationale: The nurse should clean the wound from the center outward to prevent
introduction of micro-organisms from the outer skin surface. The nurse should wear clean
gloves to remove the old dressing, not sterile gloves. The nurse should warm the
irrigation solution to body temperature.
The nurse should use a 35-mL syringe to irrigate the wound. Syringes that hold 30 to 60
mL of fluid create a safe but effective amount of pressure for wound irrigation.
6. A nurse is admitting a client who has rubella. Which of the following types of
transmission-based precautions should the nurse initiate?
Correct
Answer✅:
Droplet
Rationale: Droplet precautions are a requirement for clients who have infections that
spread via droplet nuclei that are larger than 5 microns in diameter, including influenza,
rubella, meningococcal pneumonia, and streptococcal pharyngitis. Airborne precautions
are a requirement for clients who have infections that spread via droplet nuclei that are
smaller than 5 microns in diameter, including varicella, tuberculosis, and measles.
pg. 2
, 3
RN Fundamentals Online Practice 2019 B
7. A nurse is providing discharge teaching for a client who has a new prescription for a
home oxygen concentrator. Which of the following instructions should the nurse
provide to the client and his family? (Select all that apply.)
Correct Answer✅: Check the cord routinely for frays or tearing; consider purchasing a
generator for power backup; observe for signs of hypoxia
Rationale: Oxygen concentrators require electrical power. Safe use of this delivery
system includes assessing the electrical function of the device; therefore, the nurse should
instruct the client to routinely check the condition of the cord. Loss of electricity prevents
the oxygen concentrator from functioning and could deprive the client of necessary
oxygen. The nurse should also instruct the family to have the client placed on their
municipality's priority list for restoring power after an outage occurs. The nurse should
instruct the family to observe for and report signs of hypoxia, such as anxiety, worsening
fatigue, dizziness, rapid pulse and respirations, pallor, and cyanosis. Even with
supplemental oxygen, the client's status can worsen, resulting in the development of
hypoxia.
8. A nurse is calculating a client’s fluid intake over the past 8 hr. which of the following
items should the nurse plan to document on the client’s intake and output record as 120
mL of fluid?
Correct Answer✅: 8 oz of ice chips
Rationale: The nurse should document half of the volume of ice chips when
calculating fluid intake to account for the air in between the chips. The nurse should
understand that 4 oz of liquid water is equal to 120 mL of fluid.
9. A nurse is caring for a client who has tuberculosis. Which of the following actions
should the nurse take? (Select all that apply.)
Correct Answer✅: Place the client in a room with negative-pressure airflow; wear
gloves when assisting the client with oral care; use antimicrobial sanitizer for hand
hygiene
Rationale: The nurse should place the client in a room with negative-pressure airflow to
meet the requirements of airborne precautions. The nurse should wear gloves when
assisting the client with oral care to meet the requirements of standard precautions,
which the nurse must adhere to for all clients regardless of their diagnosis. The nurse
should wear gloves whenever their hands might come in contact with a client's bodily
pg. 3
