Fundamentals A
1. 1.
ID:31 236316
Anel
der
lycl
ientwi
thafr
actur
edl
efthi
pisonst
ri
ctbedr
est
.Whi
chnur
singmeasur
eisesent
i
al
t
othecl
i
ent'
snursi
ngcare?
A. Masageanyr
ed enedar
easf
oratl
eas
tfiv
emi
nut
es.
B. Encour
ageact
i
ver
angeofmot
i
onex
erci
sesonext
remi
t
ies
.
C. Posi
t
iont
hecl
i
entl
ater
aly
,pr
one,anddor
sal
yinsequence.
D. Gent
l
yli
fthecl
i
entwhenmovi
ngi
ntoadesi
redposi
t
ion.
Cor
rect
Toavoi dsheari
ngf orceswhenr eposi
ti
oni
ng,thecli
entshoul
dbel i
ft
edgent l
yacros asurf
ace
(D).Red enedar easshouldnotbemasaged( A)sincethi
smayi ncreasethedamageto
alr
eadyt r
aumat i
zeds kin.Tocontr
olpainandmus cl
espasms ,acti
verangeofmot i
on(B)maybe
l
imitedont heafectedleg.Thepositi
ondescr
ibedin(C)iscontr
aindi
catedforacli
entwit
ha
fr
acturedlefthi
p.
Awar
ded0.
0poi
ntsoutof1.
0posi
bl
epoi
nts
.
2. 2.
ID:31 2595 8
Thenursei
sadmini
ster
ingmedicat
i
onsthroughanasogast
ri
ctube(NGT)whi
chiscon ect
edt
o
suct
i
on.Aft
erensur
ingcorr
ectubeplacement,whatact
i
onshouldt
henurset
akenext
?
A. Cl
ampt
het
ubef
or20mi
nut
es.
B. Fl
usht
het
ubewi
t
hwat
er.
Cor
rect
C. Admi
ni
st
ert
hemedi
cat
i
onsaspr
escr
ibed.
D. Cr
usht
het
abl
etsanddi
sol
vei
nst
eri
l
ewat
er.
TheNGTshoul
dbeflushedbefor
e,af t
erandinbet
we neachmedi cat
ionadmini
st
ered(B).
Oncealmedi
cat
ionsar eadmini
stered,t
heNGTshoul dbecl ampedfor20minut
es( A)
.(Cand
D)maybeimpl
ement edonlyaft
erthetubinghasbe nflushed.
, Awar
ded0.
0poi
ntsoutof1.
0posi
bl
epoi
nts
.
3. 3.
ID:31 201 02
Acli
entwhoisi
nhospi
cecar
ecompl ai
nsofi
ncr
easingamount
sofpain.Theheal
thcar
eprovi
der
pr
escri
besananal
gesi
cever
yfourhoursasne ded.Whi
chact
ionshouldthenur
seimplement
?
A. Gi
veanar
ound-
the-
clockschedul
eforadmi
ni
st
rat
i
onofanal
gesi
cs.
Cor
rect
B. Admi
ni
st
eranal
gesi
cmedi
cat
i
onasne dedwhent
hepai
nissev
ere.
C. Pr
ovi
demedi
cat
i
ont
oke pt
hecl
i
entsedat
edandunawar
eofs
ti
mul
i
.
D. Oferamedi
cat
i
on-
fr
e per
iodsot
hathecl
i
entcandodai
l
yact
i
vit
i
es.
Themos tefectivemanagementofpai nisachievedusinganar ound-the-
clockschedul
ethat
provi
desanal gesicmedicat
ionsonar egularbasis(A)andinat i
mel yman er.Analgesi
csar e
l
es efect
iveifpai npersi
st
sunt i
li
tissevere,soananal gesi
cmedi cati
onshouldbeadmi ni
stered
befor
ethecl i
ent '
spainpeaks(B).Provi
dingcomf or
tisapr i
ori
tyforthecli
entwhoi sdyi
ng,but
sedati
onthati mpair
sthecli
ent'sabil
i
tytointer
actandexper i
encet heti
mebef or
elif
eends
shoul
dbemi nimized(C).Oferi
ngamedi cati
on-f
re periodalowst heserum druglevelt
ofal,
whichisnotanefect i
vemethodt omanagechr onicpain(D).
Awar
ded0.
0poi
ntsoutof1.
0posi
bl
epoi
nts
.
4. 4.
ID:31 212896
Whenasesingacli
entwi
t
hwr i
str
est
rai
nts,t
henur
seobser v
est
hathef
inger
sont
her
ight
handar
ebl
ue.Whatact
i
onshoul
dthenurseimpl
ementf
ir
st?
A. Lo sent
her
ightwr
istr
est
rai
nt.
Cor
rect
B. Ap l
yapul
seoxi
met
ert
other
ighthand.
C. Compar
ehandcol
orbi
l
ater
aly
.
D. Pal
pat
ether
ightr
adi
alpul
se.
, Thepr i
oritynursingact i
oni
storestorecircul
ati
onbylo seni
ngther est
rai
nt(A),becausebl ue
f
inger
s(c yanosis)indi
catesdecr
easedci rcul
ati
on.(CandD)ar ealsoimportantnursing
inter
venti
ons ,butdonothav ethepr i
orit
yof(A).Pulseoxi
metr
y(B)measur esthes atur
ati
onof
hemogl obinwithoxy genandisnotindicatedinsit
uati
onswherethec yanosisi
srelatedto
mechani calcompr esi on(t
herest
raints).
Awar
ded0.
0poi
ntsoutof1.
0posi
bl
epoi
nts
.
5. 5.
ID:31 2056 4
Thenurseisasesingthenut
rit
ional
statusofsev
eral
cli
ent
s.Whi
chcl
i
enthast
hegr
eat
est
nut
ri
ti
onalne df
orad i
t
ionali
ntakeofprotei
n?
A. Acol
ege-
aget
rackr
un erwi
t
haspr
ainedankl
e.
B. Al
act
ati
ngwomannur
singher3-
day
-ol
dinf
ant.
Cor
rect
C. As
cho l
-agedchi
l
dwi
t
hType2di
abet
es.
D. Anel
der
lymanbei
ngt
reat
edf
orapept
i
cul
cer
.
Alact
ati
ngwoman(B)hasthegreatestne df
orad i
ti
onalpr
otei
nint
ake.(A,C,andD)ar
eal
condi
ti
onst
hatr
equi
reprot
ein,butdonothavethei
ncr
easedmetaboli
cprotei
ndemandsof
l
actat
i
on.
Awar
ded0.
0poi
ntsoutof1.
0posi
bl
epoi
nts
.
6. 6.
ID:31 269346
Acli
enti
sintheradiologydepar
tmentat090 whentheprescri
pti
onlevof
lox
aci
n(Levaqui
n)50
mgIVq24hi sscheduledtobeadmini
ster
ed.Thecl
ientr
eturnstotheunitat130 .Whati
sthe
bes
tint
ervent
ionforthenursetoi
mplement?
A. Cont
actheheal
t
hcar
epr
ovi
derandcompl
eteamedi
cat
i
onvar
iancef
orm.
B. Admi
ni
st
ert
heLevaqui
nat130 andr
esumet
he090 schedul
eint
hemor
ning.
C. Not
i
fyt
hechar
genur
seandcompl
eteani
nci
dentr
epor
toexpl
ai
nthemi
sed dose.
, D. Gi
vet
hemi
seddoseat130 andchanget
heschedul
etoadmi
ni
st
erdai
l
yat
130 .Cor
rect
Toensurethatatherapeuti
clevel ofmedi
cati
onismai
ntai
ned,thenurseshouldadmi ni
st
erthe
miseddoseasso nasposi ble,andrevi
setheadmi
nist
rat
ionscheduleacor di
nglytoprevent
dangerousl
yincr
easingthelevel ofthemedi
cati
oni
ntheblo dstr
eam (D).Thenurseshould
documenther easonforthelatedose,but(AandC)arenotwar rant
ed.(B)couldresul
tin
i
ncreasedblo dlevel
softhedr ug.
Awar
ded0.
0poi
ntsoutof1.
0posi
bl
epoi
nts
.
7. 7.
ID:31 19 864
Whil
einst
ruct
ingamal ecli
ent
'swif
eintheperf
ormanceofpasiv
erange-of
-moti
onex
erci
sest
o
hi
scontr
actedshoulder
,thenurseobser
vesthatshei
sholdi
nghi
sarm aboveandbel
owthe
el
bow.Whatnursingacti
onshouldthenursei
mplement?
A. Ack
nowl
edget
hatshei
ssup or
ti
ngt
hear
m cor
rect
l
y.Cor
rect
B. Encour
agehert
oke pt
hej
oi
ntcover
edt
omai
ntai
nwar
mth.
C. Rei
nfor
cet
hene dt
ogr
ipdi
rect
l
yundert
hej
oi
ntf
orbet
ersup or
t.
D. I
nst
ructhert
ogr
ipdi
rect
l
yov
ert
hej
oi
ntf
orbet
ermot
i
on.
Thewifeisperformi
ngt
hepasi v
eROM cor r
ectl
y,t
her
eforethenurseshoul
dack nowledget
his
f
act(A).Thejoi
nthatisbei
ngexerci
sedshoul
dbeuncov ered(B)whil
etherestofthebody
shoul
dr emai
ncoveredforwar
mthandprivacy
.(CandD)donotpr ovideadequatesup ortothe
j
ointwhil
esti
l alowi
ngforj
oi
ntmovement.
Awar
ded0.
0poi
ntsoutof1.
0posi
bl
epoi
nts
.
8. 8.
ID:31 2 3480
Whatist
hemos
timport
antr
easonf
orst
art
i
ngi
ntr
avenousi
nfusi
onsi
ntheup erext
remi
t
ies
r
athert
hant
hel
owerext
remi
ti
esofadul
t
s?
A. I
tismor
edi
fficul indasuper
tof fici
alvei
nint
hef
etandankl
es.
1. 1.
ID:31 236316
Anel
der
lycl
ientwi
thafr
actur
edl
efthi
pisonst
ri
ctbedr
est
.Whi
chnur
singmeasur
eisesent
i
al
t
othecl
i
ent'
snursi
ngcare?
A. Masageanyr
ed enedar
easf
oratl
eas
tfiv
emi
nut
es.
B. Encour
ageact
i
ver
angeofmot
i
onex
erci
sesonext
remi
t
ies
.
C. Posi
t
iont
hecl
i
entl
ater
aly
,pr
one,anddor
sal
yinsequence.
D. Gent
l
yli
fthecl
i
entwhenmovi
ngi
ntoadesi
redposi
t
ion.
Cor
rect
Toavoi dsheari
ngf orceswhenr eposi
ti
oni
ng,thecli
entshoul
dbel i
ft
edgent l
yacros asurf
ace
(D).Red enedar easshouldnotbemasaged( A)sincethi
smayi ncreasethedamageto
alr
eadyt r
aumat i
zeds kin.Tocontr
olpainandmus cl
espasms ,acti
verangeofmot i
on(B)maybe
l
imitedont heafectedleg.Thepositi
ondescr
ibedin(C)iscontr
aindi
catedforacli
entwit
ha
fr
acturedlefthi
p.
Awar
ded0.
0poi
ntsoutof1.
0posi
bl
epoi
nts
.
2. 2.
ID:31 2595 8
Thenursei
sadmini
ster
ingmedicat
i
onsthroughanasogast
ri
ctube(NGT)whi
chiscon ect
edt
o
suct
i
on.Aft
erensur
ingcorr
ectubeplacement,whatact
i
onshouldt
henurset
akenext
?
A. Cl
ampt
het
ubef
or20mi
nut
es.
B. Fl
usht
het
ubewi
t
hwat
er.
Cor
rect
C. Admi
ni
st
ert
hemedi
cat
i
onsaspr
escr
ibed.
D. Cr
usht
het
abl
etsanddi
sol
vei
nst
eri
l
ewat
er.
TheNGTshoul
dbeflushedbefor
e,af t
erandinbet
we neachmedi cat
ionadmini
st
ered(B).
Oncealmedi
cat
ionsar eadmini
stered,t
heNGTshoul dbecl ampedfor20minut
es( A)
.(Cand
D)maybeimpl
ement edonlyaft
erthetubinghasbe nflushed.
, Awar
ded0.
0poi
ntsoutof1.
0posi
bl
epoi
nts
.
3. 3.
ID:31 201 02
Acli
entwhoisi
nhospi
cecar
ecompl ai
nsofi
ncr
easingamount
sofpain.Theheal
thcar
eprovi
der
pr
escri
besananal
gesi
cever
yfourhoursasne ded.Whi
chact
ionshouldthenur
seimplement
?
A. Gi
veanar
ound-
the-
clockschedul
eforadmi
ni
st
rat
i
onofanal
gesi
cs.
Cor
rect
B. Admi
ni
st
eranal
gesi
cmedi
cat
i
onasne dedwhent
hepai
nissev
ere.
C. Pr
ovi
demedi
cat
i
ont
oke pt
hecl
i
entsedat
edandunawar
eofs
ti
mul
i
.
D. Oferamedi
cat
i
on-
fr
e per
iodsot
hathecl
i
entcandodai
l
yact
i
vit
i
es.
Themos tefectivemanagementofpai nisachievedusinganar ound-the-
clockschedul
ethat
provi
desanal gesicmedicat
ionsonar egularbasis(A)andinat i
mel yman er.Analgesi
csar e
l
es efect
iveifpai npersi
st
sunt i
li
tissevere,soananal gesi
cmedi cati
onshouldbeadmi ni
stered
befor
ethecl i
ent '
spainpeaks(B).Provi
dingcomf or
tisapr i
ori
tyforthecli
entwhoi sdyi
ng,but
sedati
onthati mpair
sthecli
ent'sabil
i
tytointer
actandexper i
encet heti
mebef or
elif
eends
shoul
dbemi nimized(C).Oferi
ngamedi cati
on-f
re periodalowst heserum druglevelt
ofal,
whichisnotanefect i
vemethodt omanagechr onicpain(D).
Awar
ded0.
0poi
ntsoutof1.
0posi
bl
epoi
nts
.
4. 4.
ID:31 212896
Whenasesingacli
entwi
t
hwr i
str
est
rai
nts,t
henur
seobser v
est
hathef
inger
sont
her
ight
handar
ebl
ue.Whatact
i
onshoul
dthenurseimpl
ementf
ir
st?
A. Lo sent
her
ightwr
istr
est
rai
nt.
Cor
rect
B. Ap l
yapul
seoxi
met
ert
other
ighthand.
C. Compar
ehandcol
orbi
l
ater
aly
.
D. Pal
pat
ether
ightr
adi
alpul
se.
, Thepr i
oritynursingact i
oni
storestorecircul
ati
onbylo seni
ngther est
rai
nt(A),becausebl ue
f
inger
s(c yanosis)indi
catesdecr
easedci rcul
ati
on.(CandD)ar ealsoimportantnursing
inter
venti
ons ,butdonothav ethepr i
orit
yof(A).Pulseoxi
metr
y(B)measur esthes atur
ati
onof
hemogl obinwithoxy genandisnotindicatedinsit
uati
onswherethec yanosisi
srelatedto
mechani calcompr esi on(t
herest
raints).
Awar
ded0.
0poi
ntsoutof1.
0posi
bl
epoi
nts
.
5. 5.
ID:31 2056 4
Thenurseisasesingthenut
rit
ional
statusofsev
eral
cli
ent
s.Whi
chcl
i
enthast
hegr
eat
est
nut
ri
ti
onalne df
orad i
t
ionali
ntakeofprotei
n?
A. Acol
ege-
aget
rackr
un erwi
t
haspr
ainedankl
e.
B. Al
act
ati
ngwomannur
singher3-
day
-ol
dinf
ant.
Cor
rect
C. As
cho l
-agedchi
l
dwi
t
hType2di
abet
es.
D. Anel
der
lymanbei
ngt
reat
edf
orapept
i
cul
cer
.
Alact
ati
ngwoman(B)hasthegreatestne df
orad i
ti
onalpr
otei
nint
ake.(A,C,andD)ar
eal
condi
ti
onst
hatr
equi
reprot
ein,butdonothavethei
ncr
easedmetaboli
cprotei
ndemandsof
l
actat
i
on.
Awar
ded0.
0poi
ntsoutof1.
0posi
bl
epoi
nts
.
6. 6.
ID:31 269346
Acli
enti
sintheradiologydepar
tmentat090 whentheprescri
pti
onlevof
lox
aci
n(Levaqui
n)50
mgIVq24hi sscheduledtobeadmini
ster
ed.Thecl
ientr
eturnstotheunitat130 .Whati
sthe
bes
tint
ervent
ionforthenursetoi
mplement?
A. Cont
actheheal
t
hcar
epr
ovi
derandcompl
eteamedi
cat
i
onvar
iancef
orm.
B. Admi
ni
st
ert
heLevaqui
nat130 andr
esumet
he090 schedul
eint
hemor
ning.
C. Not
i
fyt
hechar
genur
seandcompl
eteani
nci
dentr
epor
toexpl
ai
nthemi
sed dose.
, D. Gi
vet
hemi
seddoseat130 andchanget
heschedul
etoadmi
ni
st
erdai
l
yat
130 .Cor
rect
Toensurethatatherapeuti
clevel ofmedi
cati
onismai
ntai
ned,thenurseshouldadmi ni
st
erthe
miseddoseasso nasposi ble,andrevi
setheadmi
nist
rat
ionscheduleacor di
nglytoprevent
dangerousl
yincr
easingthelevel ofthemedi
cati
oni
ntheblo dstr
eam (D).Thenurseshould
documenther easonforthelatedose,but(AandC)arenotwar rant
ed.(B)couldresul
tin
i
ncreasedblo dlevel
softhedr ug.
Awar
ded0.
0poi
ntsoutof1.
0posi
bl
epoi
nts
.
7. 7.
ID:31 19 864
Whil
einst
ruct
ingamal ecli
ent
'swif
eintheperf
ormanceofpasiv
erange-of
-moti
onex
erci
sest
o
hi
scontr
actedshoulder
,thenurseobser
vesthatshei
sholdi
nghi
sarm aboveandbel
owthe
el
bow.Whatnursingacti
onshouldthenursei
mplement?
A. Ack
nowl
edget
hatshei
ssup or
ti
ngt
hear
m cor
rect
l
y.Cor
rect
B. Encour
agehert
oke pt
hej
oi
ntcover
edt
omai
ntai
nwar
mth.
C. Rei
nfor
cet
hene dt
ogr
ipdi
rect
l
yundert
hej
oi
ntf
orbet
ersup or
t.
D. I
nst
ructhert
ogr
ipdi
rect
l
yov
ert
hej
oi
ntf
orbet
ermot
i
on.
Thewifeisperformi
ngt
hepasi v
eROM cor r
ectl
y,t
her
eforethenurseshoul
dack nowledget
his
f
act(A).Thejoi
nthatisbei
ngexerci
sedshoul
dbeuncov ered(B)whil
etherestofthebody
shoul
dr emai
ncoveredforwar
mthandprivacy
.(CandD)donotpr ovideadequatesup ortothe
j
ointwhil
esti
l alowi
ngforj
oi
ntmovement.
Awar
ded0.
0poi
ntsoutof1.
0posi
bl
epoi
nts
.
8. 8.
ID:31 2 3480
Whatist
hemos
timport
antr
easonf
orst
art
i
ngi
ntr
avenousi
nfusi
onsi
ntheup erext
remi
t
ies
r
athert
hant
hel
owerext
remi
ti
esofadul
t
s?
A. I
tismor
edi
fficul indasuper
tof fici
alvei
nint
hef
etandankl
es.
