Comprehensive Nursing
Fundamentals Review: A Combined
Q&A Guide Covering Core Clinical
Concepts, Patient Safety, and
Evidence-Based Interventions
Question: The nurse is teaching an adult female client about health
promotion. Which of the following should the nurse recommend as a
primary prevention intervention?
Correct Answer: Receiving family planning services
Rationale: Primary prevention aims to prevent disease before it occurs.
Family planning services help prevent unintended pregnancies and
promote reproductive health before any illness develops. Breast self-
examinations and blood pressure checks are examples of secondary
prevention, which focuses on early detection .
Question: The nurse is caring for a client who has joint pain. The nurse
incorporates the nutritional status, sleep patterns, energy level, and sense
of well-being into the plan of care. Which of the following concepts is the
nurse practicing?
Correct Answer: Holism
Rationale: Holism considers the person as a whole—including physical,
emotional, social, and spiritual dimensions. By incorporating these varied
aspects into the plan of care, the nurse is addressing the whole person
rather than just the joint pain .
,Question: The community health nurse is preparing to provide education
to an adolescent client regarding health promotion. Which of the following
health promotion topics is most appropriate for this client?
Correct Answer: Peer group influences
Rationale: Adolescents are developmentally focused on peer relationships
and social acceptance. Health promotion for this age group should address
peer pressure, risky behaviors, and social influences on health decisions .
Question: The nurse is caring for a client who has a low serum albumin
level. Which statement by the nurse indicates a correct understanding of
albumin levels?
Correct Answer: "The results indicate prolonged malnutrition."
Rationale: Albumin is a protein synthesized by the liver. Low serum
albumin (normal 3.5-5.5 g/dL) typically indicates prolonged malnutrition or
liver disease because albumin has a long half-life of about 20 days .
Question: The nurse is preparing to discharge an elderly client who is at
risk for aspiration. Which of the following should the nurse recommend?
Correct Answer: Prepare liquids at prescribed consistency
Rationale: For clients at risk for aspiration, liquids should be thickened to
the prescribed consistency (nectar-thick, honey-thick, or pudding-thick).
Tilting the head back increases aspiration risk, and eating in bed is less safe
than sitting upright at 90 degrees .
Question: The nurse is administering an intermittent gastrointestinal (GT)
feeding to a client. Which of the following actions is appropriate for the
nurse to take?
Correct Answer: Raising and lowering the syringe to adjust the flow rate of
the feeding
Rationale: For intermittent gravity feedings, the height of the syringe
determines the flow rate—a higher syringe means a faster flow. Residual
,should be returned (not discarded) to prevent electrolyte imbalances unless
otherwise ordered. The head of the bed should be at 30-45 degrees .
Question: The nurse is caring for a client who is receiving prescribed
medication intravenously (IV). Upon assessment, the nurse notes the IV site
is swollen and cool to the touch. Which of the following is the most
appropriate action for the nurse to take?
Correct Answer: Stop the infusion and start supportive treatment
Rationale: A swollen and cool IV site indicates infiltration. The infusion
should be stopped immediately, and the site should be treated according
to facility policy. Slowing the rate would not resolve the infiltration .
Question: The nurse is caring for a client who is 5-days postoperative and
has been on bed rest. Which of the following interventions should the
nurse implement to decrease the client's possibility of developing
hypercalcemia?
Correct Answer: Assist the client to ambulate around the room at least 3
times daily
Rationale: Hypercalcemia can develop due to prolonged immobility
because bones release calcium when not weight-bearing. Ambulation and
weight-bearing activities help maintain bone density and prevent calcium
release .
Question: The nurse is caring for a client who has had diarrhea for 48 hours
and has developed fatigue, restlessness, and disorientation. Which of the
following laboratory results should the nurse correlate to these signs and
symptoms?
Correct Answer: Sodium
Rationale: Diarrhea causes loss of sodium and other electrolytes.
Hyponatremia (low sodium) presents with fatigue, restlessness,
disorientation, headache, and in severe cases, seizures and coma .
, Question: The nurse is caring for a client who has hypokalemia. Which of
the following signs and symptoms should the nurse expect to see?
Correct Answer: Muscle weakness
Rationale: Hypokalemia (potassium < 3.5 mEq/L) causes neuromuscular
changes including muscle weakness, fatigue, leg cramps, and decreased
reflexes. Severe hypokalemia can lead to cardiac arrhythmias and paralysis .
Question: The nurse is caring for a client who has oliguria. The nurse
recognizes that the client is experiencing:
Correct Answer: A urine output less than 30 ml/hr
Rationale: Oliguria is defined as urine output less than 400 mL in 24 hours
OR less than 30 mL/hr. This indicates decreased kidney perfusion or
intrinsic kidney damage .
Question: The nurse is assessing the following assigned older adult clients
who have urinary catheters in place. Which client should the nurse
recognize as being at greatest risk for developing a urinary tract infection
(UTI)?
Correct Answer: The client with an indwelling Foley catheter
Rationale: Indwelling urinary catheters carry the highest risk of UTI because
they provide a direct pathway for bacteria to enter the bladder. Condom
catheters are external and have a lower infection risk .
Question: The nurse is caring for a client who has a deep pressure ulcer
(Stage 3) that is heavily draining. Which of the following dressing choices
should the nurse choose to promote adequate healing?
Correct Answer: Alginate packing, dry gauze cover
Rationale: Alginate dressings are highly absorbent and are appropriate for
wounds with heavy drainage. They form a gel when in contact with wound
exudate, which helps maintain a moist wound environment. Transparent
films are for superficial wounds with minimal drainage, and wet-to-dry
gauze is less commonly used now .
Fundamentals Review: A Combined
Q&A Guide Covering Core Clinical
Concepts, Patient Safety, and
Evidence-Based Interventions
Question: The nurse is teaching an adult female client about health
promotion. Which of the following should the nurse recommend as a
primary prevention intervention?
Correct Answer: Receiving family planning services
Rationale: Primary prevention aims to prevent disease before it occurs.
Family planning services help prevent unintended pregnancies and
promote reproductive health before any illness develops. Breast self-
examinations and blood pressure checks are examples of secondary
prevention, which focuses on early detection .
Question: The nurse is caring for a client who has joint pain. The nurse
incorporates the nutritional status, sleep patterns, energy level, and sense
of well-being into the plan of care. Which of the following concepts is the
nurse practicing?
Correct Answer: Holism
Rationale: Holism considers the person as a whole—including physical,
emotional, social, and spiritual dimensions. By incorporating these varied
aspects into the plan of care, the nurse is addressing the whole person
rather than just the joint pain .
,Question: The community health nurse is preparing to provide education
to an adolescent client regarding health promotion. Which of the following
health promotion topics is most appropriate for this client?
Correct Answer: Peer group influences
Rationale: Adolescents are developmentally focused on peer relationships
and social acceptance. Health promotion for this age group should address
peer pressure, risky behaviors, and social influences on health decisions .
Question: The nurse is caring for a client who has a low serum albumin
level. Which statement by the nurse indicates a correct understanding of
albumin levels?
Correct Answer: "The results indicate prolonged malnutrition."
Rationale: Albumin is a protein synthesized by the liver. Low serum
albumin (normal 3.5-5.5 g/dL) typically indicates prolonged malnutrition or
liver disease because albumin has a long half-life of about 20 days .
Question: The nurse is preparing to discharge an elderly client who is at
risk for aspiration. Which of the following should the nurse recommend?
Correct Answer: Prepare liquids at prescribed consistency
Rationale: For clients at risk for aspiration, liquids should be thickened to
the prescribed consistency (nectar-thick, honey-thick, or pudding-thick).
Tilting the head back increases aspiration risk, and eating in bed is less safe
than sitting upright at 90 degrees .
Question: The nurse is administering an intermittent gastrointestinal (GT)
feeding to a client. Which of the following actions is appropriate for the
nurse to take?
Correct Answer: Raising and lowering the syringe to adjust the flow rate of
the feeding
Rationale: For intermittent gravity feedings, the height of the syringe
determines the flow rate—a higher syringe means a faster flow. Residual
,should be returned (not discarded) to prevent electrolyte imbalances unless
otherwise ordered. The head of the bed should be at 30-45 degrees .
Question: The nurse is caring for a client who is receiving prescribed
medication intravenously (IV). Upon assessment, the nurse notes the IV site
is swollen and cool to the touch. Which of the following is the most
appropriate action for the nurse to take?
Correct Answer: Stop the infusion and start supportive treatment
Rationale: A swollen and cool IV site indicates infiltration. The infusion
should be stopped immediately, and the site should be treated according
to facility policy. Slowing the rate would not resolve the infiltration .
Question: The nurse is caring for a client who is 5-days postoperative and
has been on bed rest. Which of the following interventions should the
nurse implement to decrease the client's possibility of developing
hypercalcemia?
Correct Answer: Assist the client to ambulate around the room at least 3
times daily
Rationale: Hypercalcemia can develop due to prolonged immobility
because bones release calcium when not weight-bearing. Ambulation and
weight-bearing activities help maintain bone density and prevent calcium
release .
Question: The nurse is caring for a client who has had diarrhea for 48 hours
and has developed fatigue, restlessness, and disorientation. Which of the
following laboratory results should the nurse correlate to these signs and
symptoms?
Correct Answer: Sodium
Rationale: Diarrhea causes loss of sodium and other electrolytes.
Hyponatremia (low sodium) presents with fatigue, restlessness,
disorientation, headache, and in severe cases, seizures and coma .
, Question: The nurse is caring for a client who has hypokalemia. Which of
the following signs and symptoms should the nurse expect to see?
Correct Answer: Muscle weakness
Rationale: Hypokalemia (potassium < 3.5 mEq/L) causes neuromuscular
changes including muscle weakness, fatigue, leg cramps, and decreased
reflexes. Severe hypokalemia can lead to cardiac arrhythmias and paralysis .
Question: The nurse is caring for a client who has oliguria. The nurse
recognizes that the client is experiencing:
Correct Answer: A urine output less than 30 ml/hr
Rationale: Oliguria is defined as urine output less than 400 mL in 24 hours
OR less than 30 mL/hr. This indicates decreased kidney perfusion or
intrinsic kidney damage .
Question: The nurse is assessing the following assigned older adult clients
who have urinary catheters in place. Which client should the nurse
recognize as being at greatest risk for developing a urinary tract infection
(UTI)?
Correct Answer: The client with an indwelling Foley catheter
Rationale: Indwelling urinary catheters carry the highest risk of UTI because
they provide a direct pathway for bacteria to enter the bladder. Condom
catheters are external and have a lower infection risk .
Question: The nurse is caring for a client who has a deep pressure ulcer
(Stage 3) that is heavily draining. Which of the following dressing choices
should the nurse choose to promote adequate healing?
Correct Answer: Alginate packing, dry gauze cover
Rationale: Alginate dressings are highly absorbent and are appropriate for
wounds with heavy drainage. They form a gel when in contact with wound
exudate, which helps maintain a moist wound environment. Transparent
films are for superficial wounds with minimal drainage, and wet-to-dry
gauze is less commonly used now .
