RN FUNDAMENTALS ONLINE PRACTICE 2023 B EXAM ACTUAL EXAM 100 QUESTIONS AND CORRECT
DETAILED ANSWERS
A nurse in a medical-surgical unit is caring for six clients. which 2 should she see first?
1. rheumatoid arthritis, C-reactive protein 3.2 mg/dL
2. history of hyperlipidemia, Cholesterol 250 mg/dL
3. 1 day postoperative. Reports pain as 8 on a scale of 0 to 10, Oxygen saturation 88%
4. new diagnosis of heart failure, Potassium 3.2 mEq/L
5. stage 2 pressure injury, Prealbumin 14 mg/dL
6. new diagnosis of diabetes mellitus, Glycosylated hemoglobin 8% - (answer) clients 3 & 4
Drop Down 1:
Client 1 is incorrect. The nurse should assess this client because the client's C-reactive protein is greater
than the expected reference range, which is an indication of inflammation. However, there is another
client the nurse should assess first.
Client 2 is incorrect. The nurse should assess this client because the client's cholesterol level is greater
than the expected reference range, which places them at risk for coronary heart disease. However, there
is another client the nurse should assess first.
Client 3 is correct. When using the airway, breathing, circulation approach to client care, the nurse
should determine that this client is the priority client to assess. The client has an oxygen saturation that
is less than the expected reference range, which is an indication of hypoxia.
Drop Down 2:
Client 4 is correct. When using the airway, breathing, circulation approach to client care, the nurse
should determine that this client is the next priority client to assess. The client has a potassium level that
is less than the expected reference range, which places the client at risk for dysrhythmias.
Client 5 is incorrect. The nurse should assess this client because their prealbumin level is less than the
expected reference range, which places them at risk for delayed wound healing. However, this client is
not the next priority client to assess.
Client 6 is incorrect. The nurse should assess this client because their glycosylated hemoglobin level is
greater than the expected reference range, which indicates poor diabetic control. However, this client is
not the next priority client to assess.
A nurse is caring for a client who has a peripheral IV inserted for fluid replacement.
Nurses' Notes
Day 1:
Lactated Ringer's at 100 mL/hr infusing into a 20-gauge IV catheter in left hand. IV dressing dry and
intact. IV site without redness or swelling. IV fluid infusing well. Day 2:
,RN FUNDAMENTALS ONLINE PRACTICE 2023 B EXAM ACTUAL EXAM 100 QUESTIONS AND CORRECT
DETAILED ANSWERS
IV site edematous. Skin surrounding catheter site taut, blanched, and cool to touch. IV fluid not infusing.
select all that apply
a. Start a new IV in the client's left hand.
b. Place a pressure dressing over the IV site.
c. Apply heat to the client's left hand.
d. Elevate the client's left arm.
e. Stop the IV infusion. - (answer) c, d, e
Stop the IV infusion is correct. The client has manifestations of IV infiltration. The nurse should stop the
IV infusion and remove the IV catheter to reduce the risk for tissue damage.
Elevate the client's left arm is correct. The nurse should elevate the client's left hand to decrease
swelling and reduce the risk for tissue damage.
Apply heat to the client's left hand is correct. The nurse should apply heat to the client's left hand to
reduce swelling and promote comfort.
Place a pressure dressing over the IV site is incorrect. The nurse should not apply pressure to the IV site,
because this can cause tissue damage.
Start a new IV in the client's left hand is incorrect. The nurse should start a new IV in a different
extremity to reduce the risk of tissue damage.
A nurse is giving a change-of-shift report about a client admitted earlier that day who has pneumonia.
Which of the following pieces of information is the priority for the nurse to provide?
a. Admitting diagnosis
b. Breath sounds
c. Body temperature
d. Diagnostic test results - (answer) b
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.
A nurse is preparing to transfer a client who can bear weight on one leg from the bed to a chair. After
securing a safe environment, which of the following actions should the nurse take next?
a. Rock the client up to a standing position.
b. Pivot on the foot that is the farthest from the chair.
, RN FUNDAMENTALS ONLINE PRACTICE 2023 B EXAM ACTUAL EXAM 100 QUESTIONS AND CORRECT
DETAILED ANSWERS
c. Assess the client for orthostatic hypotension.
d. Apply a gait belt to the client. - (answer) c
The first action the nurse should take when using the nursing process is to assess the client. The nurse
should determine the client's risk for falling or fainting during the transfer by assisting the client to sit
and dangle the feet on the side of the bed. The nurse should assess for dizziness and a significant drop in
blood pressure before assisting the client to stand and transfer into the chair.
A nurse is teaching an older adult client who is at risk for osteoporosis about beginning a program of
regular physical activity. Which of the following types of activity should the nurse recommend?
a. Walking briskly
b. Riding a bicycle
c. Performing isometric exercises
d. Engaging in high-impact aerobics - (answer) a
Weight-bearing exercises are essential for maintaining bone mass, which helps to prevent osteoporosis.
Walking engages older adult clients in this preventive and therapeutic strategy.
A nurse is caring for a client who has terminal liver cancer. Which of the following statements should the
nurse identify as an indication that the client is experiencing spiritual distress?
a. "What could I have done to deserve this illness?"
b. "I blame medical science for not curing me."
c. "Where is my daughter at a time like this?"
d. "Will I ever begin to feel in charge of my life again?" - (answer) a
The client's terminal illness might prompt the client to review their life and question its meaning. A
manifestation of the client's spiritual distress is asking why this illness is happening to them.
A nurse is reviewing protocol in preparation for suctioning secretions from a client who has a new
tracheostomy. Which of the following actions should the nurse plan to take?
a. Use a resuscitation bag with 80% oxygen prior to the procedure.
b. Select a suction catheter that is half the size of the lumen.
c. Place the end of the suction catheter in water-soluble lubricant.
d. Adjust the wall suction apparatus to a pressure of 170 mm Hg. - (answer) b
DETAILED ANSWERS
A nurse in a medical-surgical unit is caring for six clients. which 2 should she see first?
1. rheumatoid arthritis, C-reactive protein 3.2 mg/dL
2. history of hyperlipidemia, Cholesterol 250 mg/dL
3. 1 day postoperative. Reports pain as 8 on a scale of 0 to 10, Oxygen saturation 88%
4. new diagnosis of heart failure, Potassium 3.2 mEq/L
5. stage 2 pressure injury, Prealbumin 14 mg/dL
6. new diagnosis of diabetes mellitus, Glycosylated hemoglobin 8% - (answer) clients 3 & 4
Drop Down 1:
Client 1 is incorrect. The nurse should assess this client because the client's C-reactive protein is greater
than the expected reference range, which is an indication of inflammation. However, there is another
client the nurse should assess first.
Client 2 is incorrect. The nurse should assess this client because the client's cholesterol level is greater
than the expected reference range, which places them at risk for coronary heart disease. However, there
is another client the nurse should assess first.
Client 3 is correct. When using the airway, breathing, circulation approach to client care, the nurse
should determine that this client is the priority client to assess. The client has an oxygen saturation that
is less than the expected reference range, which is an indication of hypoxia.
Drop Down 2:
Client 4 is correct. When using the airway, breathing, circulation approach to client care, the nurse
should determine that this client is the next priority client to assess. The client has a potassium level that
is less than the expected reference range, which places the client at risk for dysrhythmias.
Client 5 is incorrect. The nurse should assess this client because their prealbumin level is less than the
expected reference range, which places them at risk for delayed wound healing. However, this client is
not the next priority client to assess.
Client 6 is incorrect. The nurse should assess this client because their glycosylated hemoglobin level is
greater than the expected reference range, which indicates poor diabetic control. However, this client is
not the next priority client to assess.
A nurse is caring for a client who has a peripheral IV inserted for fluid replacement.
Nurses' Notes
Day 1:
Lactated Ringer's at 100 mL/hr infusing into a 20-gauge IV catheter in left hand. IV dressing dry and
intact. IV site without redness or swelling. IV fluid infusing well. Day 2:
,RN FUNDAMENTALS ONLINE PRACTICE 2023 B EXAM ACTUAL EXAM 100 QUESTIONS AND CORRECT
DETAILED ANSWERS
IV site edematous. Skin surrounding catheter site taut, blanched, and cool to touch. IV fluid not infusing.
select all that apply
a. Start a new IV in the client's left hand.
b. Place a pressure dressing over the IV site.
c. Apply heat to the client's left hand.
d. Elevate the client's left arm.
e. Stop the IV infusion. - (answer) c, d, e
Stop the IV infusion is correct. The client has manifestations of IV infiltration. The nurse should stop the
IV infusion and remove the IV catheter to reduce the risk for tissue damage.
Elevate the client's left arm is correct. The nurse should elevate the client's left hand to decrease
swelling and reduce the risk for tissue damage.
Apply heat to the client's left hand is correct. The nurse should apply heat to the client's left hand to
reduce swelling and promote comfort.
Place a pressure dressing over the IV site is incorrect. The nurse should not apply pressure to the IV site,
because this can cause tissue damage.
Start a new IV in the client's left hand is incorrect. The nurse should start a new IV in a different
extremity to reduce the risk of tissue damage.
A nurse is giving a change-of-shift report about a client admitted earlier that day who has pneumonia.
Which of the following pieces of information is the priority for the nurse to provide?
a. Admitting diagnosis
b. Breath sounds
c. Body temperature
d. Diagnostic test results - (answer) b
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.
A nurse is preparing to transfer a client who can bear weight on one leg from the bed to a chair. After
securing a safe environment, which of the following actions should the nurse take next?
a. Rock the client up to a standing position.
b. Pivot on the foot that is the farthest from the chair.
, RN FUNDAMENTALS ONLINE PRACTICE 2023 B EXAM ACTUAL EXAM 100 QUESTIONS AND CORRECT
DETAILED ANSWERS
c. Assess the client for orthostatic hypotension.
d. Apply a gait belt to the client. - (answer) c
The first action the nurse should take when using the nursing process is to assess the client. The nurse
should determine the client's risk for falling or fainting during the transfer by assisting the client to sit
and dangle the feet on the side of the bed. The nurse should assess for dizziness and a significant drop in
blood pressure before assisting the client to stand and transfer into the chair.
A nurse is teaching an older adult client who is at risk for osteoporosis about beginning a program of
regular physical activity. Which of the following types of activity should the nurse recommend?
a. Walking briskly
b. Riding a bicycle
c. Performing isometric exercises
d. Engaging in high-impact aerobics - (answer) a
Weight-bearing exercises are essential for maintaining bone mass, which helps to prevent osteoporosis.
Walking engages older adult clients in this preventive and therapeutic strategy.
A nurse is caring for a client who has terminal liver cancer. Which of the following statements should the
nurse identify as an indication that the client is experiencing spiritual distress?
a. "What could I have done to deserve this illness?"
b. "I blame medical science for not curing me."
c. "Where is my daughter at a time like this?"
d. "Will I ever begin to feel in charge of my life again?" - (answer) a
The client's terminal illness might prompt the client to review their life and question its meaning. A
manifestation of the client's spiritual distress is asking why this illness is happening to them.
A nurse is reviewing protocol in preparation for suctioning secretions from a client who has a new
tracheostomy. Which of the following actions should the nurse plan to take?
a. Use a resuscitation bag with 80% oxygen prior to the procedure.
b. Select a suction catheter that is half the size of the lumen.
c. Place the end of the suction catheter in water-soluble lubricant.
d. Adjust the wall suction apparatus to a pressure of 170 mm Hg. - (answer) b
