Fundamentals #2
1. A nurse is reinforcing teaching about promoting rest and sleep with a client who reports insomnia. Which of the
following statements should the nurse identify as an indication that the client understands the teaching?
A. "I will walk briskly for 30 minutes before bedtime."
B. "I will limit having a glass of wine to just before bedtime."
C. "I will avoid drinking large amounts of fluids immediately before bedtime."
D. "I will do my muscle relaxation techniques in the afternoon."
2. A nurse is caring for a client has a warm, moist compress to the lower extremity. Which of the following actions
should the nurse identify as a risk to the client?
A. Heating the compress at 40.5° C (105° F)
B. Securing the moist compress with a dry towel
C. Changing the warm, moist compress frequently
D. Removing the client’s robe and blankets covering compress
3. A nurse is caring for a client who is competent, refuses further treatment, and asks to sign out of the hospital
against medical advice (AMA). The nurse notifies the charge nurse, who tells the nurse that the provider has
recommended restraining the client, if necessary, to keep her from leaving the hospital. The nurse refuses to
implement the action based on the knowledge that restraining this client would be committing which of the following
torts?
A. Invasion of privacy
B. Assault
C. Battery
D. False imprisonment
4. A nurse is administering an IM injection using a passive needle-safety device. After injection, which of the following
actions should the nurse take?
A. Activate the device immediately after injection.
B. Make sure the needle retracts into the barrel of the syringe.
C. Pull the plastic sheath over the needle.
D. Remove the safety device before disposal.
Created on:09/13/2022 Page 1
, Fundamentals #2
5. A nurse is collecting data from a client who has a wrist restraint in place. Which of the following findings should the
nurse identify as an indication of a complication of the restraint?
A. The client has a capillary refill of 1 second.
B. The client has full range of motion in her wrist.
C. The client is attempting to remove the restraint.
D. The client’s hand is cool and pale.
6. A nurse is caring for a client who has pneumonia and has been receiving oxygen therapy for several days. When
collecting data from the client, the nurse should identify which of the following findings as an indication of an
adverse effect of oxygen therapy?
A. Cracks in oral mucous membranes
B. Poor skin turgor
C. Tachycardia
D. Excessive pulmonary secretions
7. As a nurse prepares an older adult client for bed on the first night of her hospital stay, the client says, "I am afraid
that I may fall getting to the bathroom during the night. I tend to get a bit disoriented in new surroundings." Which of
the following actions should the nurse take?
A. Offer to request a prescription for an indwelling urinary catheter.
B. Keep a night light on in the client's room.
C. Limit the client's fluid intake in the evening.
D. Put the side rails up and tell the client to call for assistance to the bathroom.
8. A nurse is collecting data from a client following surgery for a brain tumor near the hypothalamus. For which of the
following findings should the nurse monitor the client because of the risks of surgery on this area of the brain?
A. Inability to regulate body temperature
B. Bradycardia
C. Visual disturbances
D. Inability to perceive sound
Created on:09/13/2022 Page 2
, Fundamentals #2
9. A nurse is collecting data from a client about pitting edema and notes an indentation of 6 mm (0.25 in) at the point
of pressure. Which of the following numbers should the nurse document to indicate the intensity of the client’s
edema?
A. 4+
B. 3+
C. 2+
D. 1+
10. A nurse is reinforcing dietary teaching with a client who is Asian-American and looks at the floor during the
instruction. Which of the following actions should the nurse take to demonstrate cultural sensitivity?
A. Check to see what is on the floor.
B. Pause and wait until the client looks up.
C. Move closer to the client.
D. Continue the discussion while avoiding eye contact.
11. A nurse is reinforcing teaching with the parents of a child who is starting to use a spacer with a metered-dose
inhaler (MDI) to treat asthma. Which of the following information should the nurse include in the teaching?
A. The spacer increases the amount of medication delivered to the oropharynx.
B. The spacer increases the amount of medication delivered to the lungs.
C. Inhale rapidly when using the spacer with the MDI.
D. Cover exhalation slots of the spacer with lips when inhaling.
12. A nurse in a long-term care facility is planning care for several clients. Which of the following activities should the
nurse plan to delegate to an assistive personnel (AP)?
A. Verifying a client’s ability to walk safely
B. Assisting a client with feeding
C. Evaluating changes to a client's pressure ulcer
D. Teaching a client how to self-administer insulin
Created on:09/13/2022 Page 3
, Fundamentals #2
13. A nurse is caring for a client who came to the emergency department with abdominal distention and is now on the
medical-surgical unit with an NG tube in place to low gastric suction. The client reports anxiety, discomfort, and a
feeling of bloating. Which of the following actions is the nurse’s priority?
A. Request a prescription for a medication to ease the client’s anxiety.
B. Irrigate the NG tube with 100 mL of sterile water.
C. Check to see if the suction equipment is working.
D. Remove and reinsert the NG tube.
14. A nurse is preparing to administer diazepam 3 mg IM. The amount available is diazepam for injection 5 mg/mL.
How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it
applies. Do not use a trailing zero.)
______ mL
15. A nurse is caring for four clients. Which of the following clients should the nurse expect to experience anticipatory
grief?
A. A client who has recently given up a child for adoption
B. A client who experiences traumatic amputation of an extremity
C. A client whose son committed suicide
D. A client who has a new diagnosis of metastatic liver cancer
16. A nurse has completed morning care for a client who requires airborne precautions. Which of the following items of
personal protective equipment (PPE) should the nurse remove first?
A. N95 mask
B. Gloves
C. Gown
D. Goggles
Created on:09/13/2022 Page 4
1. A nurse is reinforcing teaching about promoting rest and sleep with a client who reports insomnia. Which of the
following statements should the nurse identify as an indication that the client understands the teaching?
A. "I will walk briskly for 30 minutes before bedtime."
B. "I will limit having a glass of wine to just before bedtime."
C. "I will avoid drinking large amounts of fluids immediately before bedtime."
D. "I will do my muscle relaxation techniques in the afternoon."
2. A nurse is caring for a client has a warm, moist compress to the lower extremity. Which of the following actions
should the nurse identify as a risk to the client?
A. Heating the compress at 40.5° C (105° F)
B. Securing the moist compress with a dry towel
C. Changing the warm, moist compress frequently
D. Removing the client’s robe and blankets covering compress
3. A nurse is caring for a client who is competent, refuses further treatment, and asks to sign out of the hospital
against medical advice (AMA). The nurse notifies the charge nurse, who tells the nurse that the provider has
recommended restraining the client, if necessary, to keep her from leaving the hospital. The nurse refuses to
implement the action based on the knowledge that restraining this client would be committing which of the following
torts?
A. Invasion of privacy
B. Assault
C. Battery
D. False imprisonment
4. A nurse is administering an IM injection using a passive needle-safety device. After injection, which of the following
actions should the nurse take?
A. Activate the device immediately after injection.
B. Make sure the needle retracts into the barrel of the syringe.
C. Pull the plastic sheath over the needle.
D. Remove the safety device before disposal.
Created on:09/13/2022 Page 1
, Fundamentals #2
5. A nurse is collecting data from a client who has a wrist restraint in place. Which of the following findings should the
nurse identify as an indication of a complication of the restraint?
A. The client has a capillary refill of 1 second.
B. The client has full range of motion in her wrist.
C. The client is attempting to remove the restraint.
D. The client’s hand is cool and pale.
6. A nurse is caring for a client who has pneumonia and has been receiving oxygen therapy for several days. When
collecting data from the client, the nurse should identify which of the following findings as an indication of an
adverse effect of oxygen therapy?
A. Cracks in oral mucous membranes
B. Poor skin turgor
C. Tachycardia
D. Excessive pulmonary secretions
7. As a nurse prepares an older adult client for bed on the first night of her hospital stay, the client says, "I am afraid
that I may fall getting to the bathroom during the night. I tend to get a bit disoriented in new surroundings." Which of
the following actions should the nurse take?
A. Offer to request a prescription for an indwelling urinary catheter.
B. Keep a night light on in the client's room.
C. Limit the client's fluid intake in the evening.
D. Put the side rails up and tell the client to call for assistance to the bathroom.
8. A nurse is collecting data from a client following surgery for a brain tumor near the hypothalamus. For which of the
following findings should the nurse monitor the client because of the risks of surgery on this area of the brain?
A. Inability to regulate body temperature
B. Bradycardia
C. Visual disturbances
D. Inability to perceive sound
Created on:09/13/2022 Page 2
, Fundamentals #2
9. A nurse is collecting data from a client about pitting edema and notes an indentation of 6 mm (0.25 in) at the point
of pressure. Which of the following numbers should the nurse document to indicate the intensity of the client’s
edema?
A. 4+
B. 3+
C. 2+
D. 1+
10. A nurse is reinforcing dietary teaching with a client who is Asian-American and looks at the floor during the
instruction. Which of the following actions should the nurse take to demonstrate cultural sensitivity?
A. Check to see what is on the floor.
B. Pause and wait until the client looks up.
C. Move closer to the client.
D. Continue the discussion while avoiding eye contact.
11. A nurse is reinforcing teaching with the parents of a child who is starting to use a spacer with a metered-dose
inhaler (MDI) to treat asthma. Which of the following information should the nurse include in the teaching?
A. The spacer increases the amount of medication delivered to the oropharynx.
B. The spacer increases the amount of medication delivered to the lungs.
C. Inhale rapidly when using the spacer with the MDI.
D. Cover exhalation slots of the spacer with lips when inhaling.
12. A nurse in a long-term care facility is planning care for several clients. Which of the following activities should the
nurse plan to delegate to an assistive personnel (AP)?
A. Verifying a client’s ability to walk safely
B. Assisting a client with feeding
C. Evaluating changes to a client's pressure ulcer
D. Teaching a client how to self-administer insulin
Created on:09/13/2022 Page 3
, Fundamentals #2
13. A nurse is caring for a client who came to the emergency department with abdominal distention and is now on the
medical-surgical unit with an NG tube in place to low gastric suction. The client reports anxiety, discomfort, and a
feeling of bloating. Which of the following actions is the nurse’s priority?
A. Request a prescription for a medication to ease the client’s anxiety.
B. Irrigate the NG tube with 100 mL of sterile water.
C. Check to see if the suction equipment is working.
D. Remove and reinsert the NG tube.
14. A nurse is preparing to administer diazepam 3 mg IM. The amount available is diazepam for injection 5 mg/mL.
How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it
applies. Do not use a trailing zero.)
______ mL
15. A nurse is caring for four clients. Which of the following clients should the nurse expect to experience anticipatory
grief?
A. A client who has recently given up a child for adoption
B. A client who experiences traumatic amputation of an extremity
C. A client whose son committed suicide
D. A client who has a new diagnosis of metastatic liver cancer
16. A nurse has completed morning care for a client who requires airborne precautions. Which of the following items of
personal protective equipment (PPE) should the nurse remove first?
A. N95 mask
B. Gloves
C. Gown
D. Goggles
Created on:09/13/2022 Page 4
