Review 2024/2025 | 400+ Updated Practice Questions
with Detailed Rationales & Complete Nursing
Fundamentals Study Guide
1.. A nurse is caring for a client who has a tracheostomy and requires suctioning. Which of the
following actions should the nurse take?
A. Hyper oxygenate the client before suctioning
-The nurse should use a manual resuscitation bag to hyper oxygenate the client for several minutes prior
to suctioning.
B. Insert the catheter during exhalation
-incorrect: The nurse should insert the catheter during inhalation
C. Apply suction during insertion of the catheter
-incorrect: Applying suction while inserting the catheter increases the risk of damage to the tracheal
mucosa and removes oxygen from the airways.
D. Apply suction for no more than 15 secs
-incorrect: The nurse should apply suction for no more than 10 seconds
2. A nurse is caring for a client who has bilateral cats on her hands. Which of the following actions
should the nurse take when assisting the client with feeding?
A. Sit at the bedside when feeding the client
-The nurse should avoid appearing to be in a hurry. Sitting at the bedside provides the client with
thenurse’s full attention during the feedingOrder pureed foods
-incorrect: Without any mouth or throat injuries that make chewing or swallowing difficult, the client
should be served foods of an appropriate variety of textures. Pureed foods are for clients who cannot
chew, have difficulty swallowing, or do not have teeth. B. Make sure feedings are provided at room
temperature
-incorrect: The nurse should ask the client if the food is the correct temperature
,C. Offer the client a drink of fluid after every bite
-incorrect: If the client is unable to communicate, the nurse should offer the client fluids after every 3 or 4
mouthfuls. However, there is no indication that this client is unable to communicate. Therefore, the client
should tell the nurse when she would like a drink.
3. A nurse is providing teaching to a client regarding protein intake. Which of the following foods
should the nurse include as an example of an incomplete protein?
A. Eggs
-incorrect: this is a complete protein, contains all of the essential amino acids necessary for the
synthesis of protein in the body.
B. Soybeans
-incorrect: this is a complete protein, contains all of the essential amino acids necessary for the
synthesis of protein in the body.
C. Lentils
-Incomplete proteins are missing 1 or more of the essential amino acids necessary for the synthesis of
protein in the body. Examples of incomplete proteins include lentils, vegetables, grains, nuts, and
seeds.
D. Yogurt
-incorrect: this is a complete protein, contains all of the essential amino acids necessary for the
synthesis of protein in the body.
4. A nurse is caring for a client who was admitted to a long-term care facility for rehabilitation after a
total hip arthroplasty. At which of the following times should the nurse begin discharge planning? A.
One week prior to the client’s discharge
-incorrect: Beginning to plan for the clien
,C. Position the client on his left side
-Positioning is an important aspect of administering an enema. Having the client lie on his left side
facilitates the flow of the enema solution into the sigmoid and descending colon.
D. Hold the solution bag 91 cm (36 inch) above the client’s rectum
-incorrect: The nurse should hold the solution bag 30 cm (12 in) above the client’s rectum for a low
enema and 45 cm (18 in) for a high enema. If the nurse holds the solution bag too high, the solution
might run in too fast, causing discomfort and spasms that make retaining the enema more difficult.
6. A nurse is administering an IM injection to a 5-month-old infant. Which of the following
injection sites should the nurse use? A. Deltoid
-incorrect: The nurse can use the deltoid muscle for injecting small volumes of medication for children
18 months of age or older, but its proximity to several nerves and arteries make it a riskier choice.
B. Ventrogluteal
-incorrect: This is a safe site for IM injections for clients older than 7 months.
C. Vastus lateralis
-The nurse should use the vastus lateralis site over the anterior thigh for IM injections for infants and
children. D. Dorsogluteal
-incorrect: This site is unsafe to use because of its proximity to the sciatic nerve and the superior gluteal
nerve and artery.
7. A nurse is caring for a client who has major fecal incontinence and reports irritation in the perianal
area. Which of the following actions should the nurse take first?
A. Apply a fecal collection system
-incorrect: The nurse should apply a fecal collection system to divert the feces away from the area of
skin irritation; however, there is another action the nurse should take first.
B. Apply a barrier cream
-incorrect: The nurse should apply a barrier cream to decrease skin breakdown in the perianal area
from the feces; however, there is another action the nurse should take first.
C. Cleanse and dry the area
-incorrect: The nurse should cleanse and dry the perianal area to decrease skin irritation;
however, there is another action the nurse should take first.
D. Check the client’s perineum
-The nurse should apply the nursing process priority-setting framework to plan care and prioritize nursing
actions. Each step of the nursing process builds on the previous step, beginning with an assessment or
data collection. Before the nurse can formulate a plan of action, implement a nursing intervention, or
notify a provider of a change in the client’s status, the nurse must first collect adequate data from the
, client. Assessing or collecting additional data will provide the nurse with knowledge to make an
appropriate decision. The priority nursing action is for the nurse to collect more data by assessing the area
of irritation.