LEARNING SYSTEM RN 2.0 – FUNDAMENTALS FINAL
1. A nurse is using the I-SBAR communication tool to provide the client’s provider with
information about the client. The nurse should convey the client’s pain status in which portion of
the report?
- Assessment
- Background
- Situation
- Recommendation
The nurse provides information about assessment findings in this portion of the report. This includes vital
signs, pain assessment, and changes in assessment findings.
2. A nurse is providing discharge teaching to a client who is recovering from lung cancer. The
provider instructed the client that he could resume lower-intensity activities of daily living.
Which of the following activities should the nurse recommend to the client?
- Sweeping the floor
- Shoveling snow
- Cleaning windows
- Washing dishes
Washing dishes requires a low level of activity and is appropriate for this client.
3. A nurse in the emergency department is caring for a client who has abdominal trauma. Which
of the following assessment findings should the nurse identify as an indication of hypovolemic
shock?
- Warm, dry skin
- Increased urinary output
- Tachycardia
- Bradypnea
Due to the decrease in circulating blood volume that occurs with internal bleeding, the oxygen-carrying
capacity of the blood is reduced. The body attempts to relieve the hypoxia by increasing the heart rate
and cardiac output, along with increasing the respiratory rate.
4. A nurse is planning to assess the abdomen of a client who reports feeling bloated for several
weeks. Which of the following methods of assessment should the nurse use first?
- Inspection
- Auscultation
- Percussion
- Palpation
According to evidence-based practice, the nurse should inspect the abdomen first by observing the
contour of the abdomen, the condition of the skin, and the position of the umbilicus. Findings from this
step of assessment are used by the nurse in the subsequent steps.
5. A nurse is responding to a parent’s question about his infant’s expected physical development
during the first year of life. Which of the following information should the nurse include?
- A 2-month-old infant can turn from his abdomen to his back.
- A 10-month-old infant can pull up to a standing position.
- A 4-month-old infant can sit up without support.
, - A 6-month-old infant can crawl on his hands and knees.
An 8 to 10-month-old infant can pull himself to a standing position.
6. A client who reports shortness of breath requests her nurse’s help in changing positions. After
repositioning the client, which of the following actions should the nurse take next?
- Encourage the client to take deep breaths.
- Observe the rate, depth, and character of the client’s respirations.
- Prepare to administer oxygen.
- Give the client a back rub to help her relax.
The nurse should apply the nursing process priority-setting framework when caring for this client. The
nurse can use the nursing process to plan client care and prioritize nursing actions. Each step of the
nursing process builds on the previous step, beginning with 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; therefore, the
first action the nurse should take is to assess the client's respiratory status.
7. A nurse is planning to insert a nasogastric tube for a client after explaining the procedure. The
client states, “You are not putting that hose down my throat.” Which of the following statements
should the nurse make?
- “I would try to get it over with because you won’t get better without this tube.”
- “You should talk to your provider about it.”
- “Why don’t you want the tube inserted?”
- “I can see that this is upsetting you.”
The nurse is using the therapeutic communication techniques of reflecting and restating, which
encourages communication by the client.
8. An assistive personnel (AP) is assisting a nurse with the care of a female client who has an
indwelling urinary catheter. Which of the following actions by the AP indicates a need for
further teaching?
- The AP uses soap and water to clean the perineal area.
- The AP tapes the catheter to the client’s inner thigh.
- The AP hangs the collection bag at the level of the bladder.
- The AP ensures that there are no kinks in the drainage tubing.
The AP should place the drainage bag below the level of the bladder to ensure proper drainage by gravity.
9. A nurse is explaining the use of written consent forms to a newly-licensed nurse. The nurse
should ensure that a written consent form has been signed by which of the following clients?
- A client who has a prescription for a transfusion of packed red blood cells
- A client who is being transported for radiography of the kidneys, ureters, and bladder
- A client who has a prescription for a tuberculin skin test
- A client who has a distended bladder and needs urinary catheterization
Administration of blood is a procedure that carries risk; therefore, the client must sign a consent form
prior to the procedure.
1. A nurse is using the I-SBAR communication tool to provide the client’s provider with
information about the client. The nurse should convey the client’s pain status in which portion of
the report?
- Assessment
- Background
- Situation
- Recommendation
The nurse provides information about assessment findings in this portion of the report. This includes vital
signs, pain assessment, and changes in assessment findings.
2. A nurse is providing discharge teaching to a client who is recovering from lung cancer. The
provider instructed the client that he could resume lower-intensity activities of daily living.
Which of the following activities should the nurse recommend to the client?
- Sweeping the floor
- Shoveling snow
- Cleaning windows
- Washing dishes
Washing dishes requires a low level of activity and is appropriate for this client.
3. A nurse in the emergency department is caring for a client who has abdominal trauma. Which
of the following assessment findings should the nurse identify as an indication of hypovolemic
shock?
- Warm, dry skin
- Increased urinary output
- Tachycardia
- Bradypnea
Due to the decrease in circulating blood volume that occurs with internal bleeding, the oxygen-carrying
capacity of the blood is reduced. The body attempts to relieve the hypoxia by increasing the heart rate
and cardiac output, along with increasing the respiratory rate.
4. A nurse is planning to assess the abdomen of a client who reports feeling bloated for several
weeks. Which of the following methods of assessment should the nurse use first?
- Inspection
- Auscultation
- Percussion
- Palpation
According to evidence-based practice, the nurse should inspect the abdomen first by observing the
contour of the abdomen, the condition of the skin, and the position of the umbilicus. Findings from this
step of assessment are used by the nurse in the subsequent steps.
5. A nurse is responding to a parent’s question about his infant’s expected physical development
during the first year of life. Which of the following information should the nurse include?
- A 2-month-old infant can turn from his abdomen to his back.
- A 10-month-old infant can pull up to a standing position.
- A 4-month-old infant can sit up without support.
, - A 6-month-old infant can crawl on his hands and knees.
An 8 to 10-month-old infant can pull himself to a standing position.
6. A client who reports shortness of breath requests her nurse’s help in changing positions. After
repositioning the client, which of the following actions should the nurse take next?
- Encourage the client to take deep breaths.
- Observe the rate, depth, and character of the client’s respirations.
- Prepare to administer oxygen.
- Give the client a back rub to help her relax.
The nurse should apply the nursing process priority-setting framework when caring for this client. The
nurse can use the nursing process to plan client care and prioritize nursing actions. Each step of the
nursing process builds on the previous step, beginning with 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; therefore, the
first action the nurse should take is to assess the client's respiratory status.
7. A nurse is planning to insert a nasogastric tube for a client after explaining the procedure. The
client states, “You are not putting that hose down my throat.” Which of the following statements
should the nurse make?
- “I would try to get it over with because you won’t get better without this tube.”
- “You should talk to your provider about it.”
- “Why don’t you want the tube inserted?”
- “I can see that this is upsetting you.”
The nurse is using the therapeutic communication techniques of reflecting and restating, which
encourages communication by the client.
8. An assistive personnel (AP) is assisting a nurse with the care of a female client who has an
indwelling urinary catheter. Which of the following actions by the AP indicates a need for
further teaching?
- The AP uses soap and water to clean the perineal area.
- The AP tapes the catheter to the client’s inner thigh.
- The AP hangs the collection bag at the level of the bladder.
- The AP ensures that there are no kinks in the drainage tubing.
The AP should place the drainage bag below the level of the bladder to ensure proper drainage by gravity.
9. A nurse is explaining the use of written consent forms to a newly-licensed nurse. The nurse
should ensure that a written consent form has been signed by which of the following clients?
- A client who has a prescription for a transfusion of packed red blood cells
- A client who is being transported for radiography of the kidneys, ureters, and bladder
- A client who has a prescription for a tuberculin skin test
- A client who has a distended bladder and needs urinary catheterization
Administration of blood is a procedure that carries risk; therefore, the client must sign a consent form
prior to the procedure.
