RN Fundamentals 2026
Question 1
A nurse is caring for four clients. Which client should the nurse assess first?
A. A client 2 days postoperative who reports pain rated 8 on a scale of 0 to 10.
B. A client with chronic heart failure who has 2+ bilateral ankle edema.
C. A client receiving a blood transfusion who reports chills and low back pain.
D. A client scheduled for discharge who needs medication teaching.
Correct Answer: C
Rationale: Chills and low back pain during a blood transfusion suggest an acute hemolytic
transfusion reaction. The transfusion should be stopped immediately, and the client assessed.
,Question 2
A nurse is preparing to administer digoxin to an adult client. Which assessment finding requires
the nurse to withhold the medication?
A. Apical pulse of 56/min
B. Blood pressure of 138/82 mm Hg
C. Respiratory rate of 18/min
D. Oxygen saturation of 95%
Correct Answer: A
Rationale: Digoxin should be withheld if the adult apical pulse is less than 60/min because of
the risk of severe bradycardia.
,Question 3
A nurse is preparing to insert an indwelling urinary catheter using sterile technique. Which
action requires intervention by the charge nurse?
A. Opens the sterile kit away from the body.
B. Dons sterile gloves after opening the kit.
C. Reaches across the sterile field to obtain supplies.
D. Cleans the urinary meatus using sterile swabs.
Correct Answer: C
Rationale: Reaching across a sterile field contaminates the field and breaks sterile technique.
, Question 4
A nurse is caring for a client who suddenly develops shortness of breath and oxygen saturation
decreases to 82%. Which action should the nurse take first?
A. Notify the provider.
B. Apply oxygen via face mask.
C. Obtain arterial blood gases.
D. Document the assessment findings.
Correct Answer: B
Rationale: According to the ABC priority framework, maintaining oxygenation is the immediate
priority.
Question 1
A nurse is caring for four clients. Which client should the nurse assess first?
A. A client 2 days postoperative who reports pain rated 8 on a scale of 0 to 10.
B. A client with chronic heart failure who has 2+ bilateral ankle edema.
C. A client receiving a blood transfusion who reports chills and low back pain.
D. A client scheduled for discharge who needs medication teaching.
Correct Answer: C
Rationale: Chills and low back pain during a blood transfusion suggest an acute hemolytic
transfusion reaction. The transfusion should be stopped immediately, and the client assessed.
,Question 2
A nurse is preparing to administer digoxin to an adult client. Which assessment finding requires
the nurse to withhold the medication?
A. Apical pulse of 56/min
B. Blood pressure of 138/82 mm Hg
C. Respiratory rate of 18/min
D. Oxygen saturation of 95%
Correct Answer: A
Rationale: Digoxin should be withheld if the adult apical pulse is less than 60/min because of
the risk of severe bradycardia.
,Question 3
A nurse is preparing to insert an indwelling urinary catheter using sterile technique. Which
action requires intervention by the charge nurse?
A. Opens the sterile kit away from the body.
B. Dons sterile gloves after opening the kit.
C. Reaches across the sterile field to obtain supplies.
D. Cleans the urinary meatus using sterile swabs.
Correct Answer: C
Rationale: Reaching across a sterile field contaminates the field and breaks sterile technique.
, Question 4
A nurse is caring for a client who suddenly develops shortness of breath and oxygen saturation
decreases to 82%. Which action should the nurse take first?
A. Notify the provider.
B. Apply oxygen via face mask.
C. Obtain arterial blood gases.
D. Document the assessment findings.
Correct Answer: B
Rationale: According to the ABC priority framework, maintaining oxygenation is the immediate
priority.
