Fundamentals of Nursing Practice –
Complete Exam 19 with Verified
Answers (2026 Edition)
Question 1: A nurse is preparing to perform a sterile dressing change. Which action is correct when
opening a sterile package?
A) Open the package away from the body, keeping the inner surface sterile
B) Open the package toward the body to ensure the sterile field is visible
C) Touch the inner surface of the package with bare hands
D) Place the package on a wet surface to stabilize it
Answer: A) Open the package away from the body, keeping the inner surface sterile
Rationale: When opening a sterile package, the nurse should open the package away from the body to
prevent contamination of the inner sterile surface. The inner surface should not be touched with bare
hands, and the package should be placed on a clean, dry surface. Maintaining the sterility of the field is
essential to prevent infection. The outer 1-inch border of the sterile field is considered contaminated.
Question 2: A nurse is performing a focused respiratory assessment on a client with shortness of breath.
Which finding indicates the client is using accessory muscles to breathe?
A) Pursed-lip breathing
B) Nasal flaring
C) Retractions of the intercostal spaces
D) All of the above
Answer: D) All of the above
Rationale: Use of accessory muscles to breathe indicates increased work of breathing and respiratory
distress. Signs include pursed-lip breathing, nasal flaring, retractions (intercostal, supraclavicular,
substernal), and use of the sternocleidomastoid muscles. The nurse should assess the client's respiratory
rate, depth, and breath sounds, and administer oxygen and other interventions as prescribed.
Question 3: A nurse is preparing to administer a medication via the subcutaneous route. Which needle
gauge and length are most appropriate?
A) 18-gauge, 1.5-inch needle
B) 25-gauge, 5/8-inch needle
,C) 22-gauge, 1-inch needle
D) 20-gauge, 1.5-inch needle
Answer: B) 25-gauge, 5/8-inch needle
Rationale: Subcutaneous injections are administered into the fatty tissue layer below the skin. A 25-
gauge, 5/8-inch needle is appropriate for subcutaneous injections. The site should be rotated, and the
volume should be limited to 1-2 mL. The nurse should pinch the skin to lift the subcutaneous tissue and
insert the needle at a 45-90 degree angle, depending on the client's body mass and the amount of
subcutaneous tissue.
Question 4: A nurse is caring for a client with a nasogastric (NG) tube who is receiving continuous
enteral feeding. Which action should the nurse take to prevent aspiration?
A) Keep the head of the bed elevated to 30-45 degrees
B) Check gastric residual volumes every 4 hours
C) Monitor for signs of aspiration (coughing, fever, dyspnea)
D) All of the above
Answer: D) All of the above
Rationale: Preventing aspiration in clients with NG tubes involves keeping the head of the bed elevated
to 30-45 degrees (to use gravity to keep gastric contents in the stomach), checking gastric residual
volumes every 4 hours (to assess for delayed gastric emptying), and monitoring for signs of aspiration
(coughing, fever, dyspnea, decreased oxygen saturation). If residual volume is >250 mL, the feeding
should be held and the healthcare provider notified.
Question 5: A nurse is assessing a client's pain using the PQRST mnemonic. Which question addresses
the "Quality" of the client's pain?
A) "Where is your pain located?"
B) "What does the pain feel like?"
C) "What makes the pain worse?"
D) "How does the pain affect your daily activities?"
Answer: B) "What does the pain feel like?"
Rationale: The PQRST mnemonic is used to assess pain: Provocation/Palliation (what makes it
better/worse), Quality (what does it feel like? sharp, dull, burning, aching), Region/Radiation (where is it,
does it radiate), Severity (0-10 scale), and Timing (onset, duration, frequency). Asking "What does the
pain feel like?" addresses the quality of the pain. This assessment helps identify the type of pain and
guide appropriate interventions.
Question 6: A nurse is preparing to transfer a client from a bed to a chair. Which action should the nurse
take first?
, A) Place the chair next to the bed on the client's stronger side
B) Ensure the bed is in the lowest position with brakes locked
C) Assess the client's ability to bear weight
D) Ask the client to sit up and dangle their legs
Answer: C) Assess the client's ability to bear weight
Rationale: Before transferring a client, the nurse should first assess the client's ability to bear weight,
level of consciousness, and strength to ensure a safe transfer. After assessment, the nurse should ensure
the bed is in the lowest position with brakes locked, place the chair on the client's stronger side, and
assist the client to sit up and dangle their legs. Using a transfer belt and having assistance may be
needed for clients who are weak or unsteady.
Question 7: A nurse is assessing a client's pulse. The pulse is noted to be irregular, with a rate of 88
beats per minute. Which action should the nurse take?
A) Document the pulse as irregular and continue monitoring
B) Assess the pulse for a full 60 seconds
C) Notify the healthcare provider immediately
D) Reassess the pulse in 15 minutes
Answer: B) Assess the pulse for a full 60 seconds
Rationale: If a pulse is irregular, the nurse should assess it for a full 60 seconds to accurately determine
the rate and rhythm. An irregular pulse may indicate a cardiac arrhythmia (e.g., atrial fibrillation), which
requires further assessment. The nurse should document the rate, rhythm, and any irregularities. The
healthcare provider should be notified if there are other signs of cardiac dysfunction (chest pain,
shortness of breath, dizziness).
Question 8: A nurse is preparing to administer an oral medication to a client who has difficulty
swallowing. Which action should the nurse take?
A) Crush the medication and mix it with applesauce
B) Ask the pharmacist if the medication is available in a liquid form
C) Administer the medication with a full glass of water
D) Place the medication under the tongue
Answer: B) Ask the pharmacist if the medication is available in a liquid form
Rationale: If a client has difficulty swallowing, the nurse should first ask the pharmacist if the medication
is available in a liquid form or if it can be crushed (not all medications can be crushed; enteric-coated,
extended-release, and sublingual medications should not be crushed). Crushing a medication without
checking may alter its absorption, effectiveness, or cause adverse effects. The nurse should also assess
the client's ability to swallow and provide appropriate assistance.
Complete Exam 19 with Verified
Answers (2026 Edition)
Question 1: A nurse is preparing to perform a sterile dressing change. Which action is correct when
opening a sterile package?
A) Open the package away from the body, keeping the inner surface sterile
B) Open the package toward the body to ensure the sterile field is visible
C) Touch the inner surface of the package with bare hands
D) Place the package on a wet surface to stabilize it
Answer: A) Open the package away from the body, keeping the inner surface sterile
Rationale: When opening a sterile package, the nurse should open the package away from the body to
prevent contamination of the inner sterile surface. The inner surface should not be touched with bare
hands, and the package should be placed on a clean, dry surface. Maintaining the sterility of the field is
essential to prevent infection. The outer 1-inch border of the sterile field is considered contaminated.
Question 2: A nurse is performing a focused respiratory assessment on a client with shortness of breath.
Which finding indicates the client is using accessory muscles to breathe?
A) Pursed-lip breathing
B) Nasal flaring
C) Retractions of the intercostal spaces
D) All of the above
Answer: D) All of the above
Rationale: Use of accessory muscles to breathe indicates increased work of breathing and respiratory
distress. Signs include pursed-lip breathing, nasal flaring, retractions (intercostal, supraclavicular,
substernal), and use of the sternocleidomastoid muscles. The nurse should assess the client's respiratory
rate, depth, and breath sounds, and administer oxygen and other interventions as prescribed.
Question 3: A nurse is preparing to administer a medication via the subcutaneous route. Which needle
gauge and length are most appropriate?
A) 18-gauge, 1.5-inch needle
B) 25-gauge, 5/8-inch needle
,C) 22-gauge, 1-inch needle
D) 20-gauge, 1.5-inch needle
Answer: B) 25-gauge, 5/8-inch needle
Rationale: Subcutaneous injections are administered into the fatty tissue layer below the skin. A 25-
gauge, 5/8-inch needle is appropriate for subcutaneous injections. The site should be rotated, and the
volume should be limited to 1-2 mL. The nurse should pinch the skin to lift the subcutaneous tissue and
insert the needle at a 45-90 degree angle, depending on the client's body mass and the amount of
subcutaneous tissue.
Question 4: A nurse is caring for a client with a nasogastric (NG) tube who is receiving continuous
enteral feeding. Which action should the nurse take to prevent aspiration?
A) Keep the head of the bed elevated to 30-45 degrees
B) Check gastric residual volumes every 4 hours
C) Monitor for signs of aspiration (coughing, fever, dyspnea)
D) All of the above
Answer: D) All of the above
Rationale: Preventing aspiration in clients with NG tubes involves keeping the head of the bed elevated
to 30-45 degrees (to use gravity to keep gastric contents in the stomach), checking gastric residual
volumes every 4 hours (to assess for delayed gastric emptying), and monitoring for signs of aspiration
(coughing, fever, dyspnea, decreased oxygen saturation). If residual volume is >250 mL, the feeding
should be held and the healthcare provider notified.
Question 5: A nurse is assessing a client's pain using the PQRST mnemonic. Which question addresses
the "Quality" of the client's pain?
A) "Where is your pain located?"
B) "What does the pain feel like?"
C) "What makes the pain worse?"
D) "How does the pain affect your daily activities?"
Answer: B) "What does the pain feel like?"
Rationale: The PQRST mnemonic is used to assess pain: Provocation/Palliation (what makes it
better/worse), Quality (what does it feel like? sharp, dull, burning, aching), Region/Radiation (where is it,
does it radiate), Severity (0-10 scale), and Timing (onset, duration, frequency). Asking "What does the
pain feel like?" addresses the quality of the pain. This assessment helps identify the type of pain and
guide appropriate interventions.
Question 6: A nurse is preparing to transfer a client from a bed to a chair. Which action should the nurse
take first?
, A) Place the chair next to the bed on the client's stronger side
B) Ensure the bed is in the lowest position with brakes locked
C) Assess the client's ability to bear weight
D) Ask the client to sit up and dangle their legs
Answer: C) Assess the client's ability to bear weight
Rationale: Before transferring a client, the nurse should first assess the client's ability to bear weight,
level of consciousness, and strength to ensure a safe transfer. After assessment, the nurse should ensure
the bed is in the lowest position with brakes locked, place the chair on the client's stronger side, and
assist the client to sit up and dangle their legs. Using a transfer belt and having assistance may be
needed for clients who are weak or unsteady.
Question 7: A nurse is assessing a client's pulse. The pulse is noted to be irregular, with a rate of 88
beats per minute. Which action should the nurse take?
A) Document the pulse as irregular and continue monitoring
B) Assess the pulse for a full 60 seconds
C) Notify the healthcare provider immediately
D) Reassess the pulse in 15 minutes
Answer: B) Assess the pulse for a full 60 seconds
Rationale: If a pulse is irregular, the nurse should assess it for a full 60 seconds to accurately determine
the rate and rhythm. An irregular pulse may indicate a cardiac arrhythmia (e.g., atrial fibrillation), which
requires further assessment. The nurse should document the rate, rhythm, and any irregularities. The
healthcare provider should be notified if there are other signs of cardiac dysfunction (chest pain,
shortness of breath, dizziness).
Question 8: A nurse is preparing to administer an oral medication to a client who has difficulty
swallowing. Which action should the nurse take?
A) Crush the medication and mix it with applesauce
B) Ask the pharmacist if the medication is available in a liquid form
C) Administer the medication with a full glass of water
D) Place the medication under the tongue
Answer: B) Ask the pharmacist if the medication is available in a liquid form
Rationale: If a client has difficulty swallowing, the nurse should first ask the pharmacist if the medication
is available in a liquid form or if it can be crushed (not all medications can be crushed; enteric-coated,
extended-release, and sublingual medications should not be crushed). Crushing a medication without
checking may alter its absorption, effectiveness, or cause adverse effects. The nurse should also assess
the client's ability to swallow and provide appropriate assistance.
